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INSANITY 



r f* F 



AND ITS TREATMENT: 

LECTURES 

oisr 

THE TREATMENT, MEDICAL AND LEGAL, OF 
INSANE PATIENTS. 

BY 

G. FIELDING BLANDFORD, M.D. Oxon., 

FELLOW OP THE ROYAL COLLEGE OF PHYSICIANS IX LONDON; 

LECTURER ON PSYCHOLOGICAL MEDICINE AT THE SCHOOL OF ST. GEORGE'S 

HOSPITAL, LONDON. 

WITH A SUMMARY 

OF THE 

LAWS IN FORCE IN THE UNITED STATES ON THE CONFINEMENT OF THE 

INSANE. 

BY ISAAC RAY, M.D. 




PHILADELPHIA: 

H E ST R Y 0. LEA. 
1871. 






Entered according to Act <>f Congress, in th< jrear 1871, • 

I'.v III.NUY ( . LEA, 
In the office of the Librarian i at Washington. All rights reserved. 



SHERMAN & CO., PRINTERS. 






PREFACE. 



The following Lectures, in an abridged form, were delivered by 
me at the School of St. George's Hospital, and I now publish them, 
with the hope that they may serve to some extent as a handy 
book concerning Insanity, on which subject there exist in our 
lano-uaee few works of the character of a text-book. 

Written for students, they make no claim to be a complete 
treatise on Psychology ; neither have all questions connected with 
Insanity been discussed in them — such as the management of 
asylums, the problem of disposing of the crowds of our chronic 
patients, or amending the present Lunacy law. 

A difficulty which has ever attended the delivery of lectures on 
Insanity is not removed when they are printed for general use. 
It is the difficulty in speaking upon the subject with the precision 
and certainty demanded by those who are learning how to deal 
medically with a grave disorder. The lecturer on Medicine, when 
speaking of diseases of lung, heart, or kidney, can lay down the 
pathology in a way that to a psychologist is at present impossible. 
He can put his linger on the exact seat of the malady, can say 
what is going on amiss during life, and what will be discovered 
after death, and can speak with exactness of both the early and 
late symptoms. Far different is it when we have to teach the 
nature or treatment of that which we call insanity — to speak not 
of respiration, circulation, or digestion, but of mind, of feelings, 
and ideas, in an abnormal or distorted state. 

Nevertheless, I am convinced that the only method by which 



IV PREFACE. 

we shall attain an insight into the mysterious phenomena of un- 
sound mind, is to keep ever before us the fact that disorder of the 
mind means disorder of the brain, and that the latter is an organ 
liable to disease and disturbance, like other organs of the body, to 
be investigated by the same methods, and subject to the same 
laws. In speaking of the pathology of insanity, I have endeavored 
to keep this in view. 

For utterances too dogmatic, for iterations and recapitulations 
too numerous, and for the too frequent presence of the personal 
pronoun, the form and style of " lectures," which I have thought 
fit to preserve, must be my apology. 

So, too, I have omitted references beyond a very few. To many 
authors, home and foreign, whose works I have consulted, I am 
under obligations not easy to acknowledge. Especially I would 
mention the now numerous volumes of the " Journal of Mental 
Science," which constitute a mine of information on this special 
subject, having, I believe, no equal. And I am not a little in- 
debted for advice, suggestions, and corrections to many friends, 
especially Drs. Broaclbent, Dickinson, and Maudsley. 

71 Grosvenor Street, London, W., 
December, 1870. 



CONTENTS. 



LECTURE I. 

PAGE 

Introductory — Impossibility of avoiding Insanity — Wiry the study 
of Insanity is a Branch of Medicine — The Organ of Mind — The 
Nerve Centres and Cells — The Nerve Fibres — Their Distribution 
— The Blood Supply of the Brain — Nerve Function — Method of 
Study Twofold, IT 

LECTURE II. 

The Phenomena of Mind — The Growth of Mind — The Divisions of 
Mind — Ideas — Feelings or Emotions — Emotions correspond to 
Ideas — Feelings vary according to the Condition of the Centres 
— Will — Conditions necessary for the Right Operation of Mind — 
A Healthy Blood-Flow — Food — A Normal Temperature — Light 
—Sleep, 38 

LECTURE III. 

The Pathology of Insanity — Characteristics of Commencing In- 
sanity — Varieties of Insanity — Insanity from Mental Shock — 
From long-continued Anxiety — Insanity in connection with the 
Sexual Organs — Puerperal Insanity — Insanity of Masturbation 
— Insanity of Alcohol — Various Forms — Insanity from other 
Poisons — From a Blow — From Excessive Heat, . . . .5*7 

LECTURE IV. 

The Pathology of Insanity, continued — Senile Insanity — General 
Paralysis — Insanity in Acute Diseases — Recurrent Insanity — 
Idiopathic Insanity — Insanity with Epilepsy — Insanity with 
Rheumatism — With Syphilis — With other Neuroses — With Dis- 
eases of the Head, Liver, Heart, Kidneys, Stomach — Insanity 
with Tuberculosis — With Peripheral Irritation — Do the Mental 
S^ymptoms correspond with the Pathological variety ? — What is 
the Pathology of Insanity? 84 



VI CONTENTS. 



LECTURE Y. 



PAGE 



Morbid Appearances — In Acute Insanity — Meninges — Brain — Ves- 
sels — In Chronic Insanity — Vessels — Brain — Nerve Cells and 
Tubes — Connective Tissue Growths — The Insane Ear — Classi- 
fication — Various Systems — Points to be observed, . . .107 



LECTURE VI. 

Causes of Insanity — Predisposing Causes or Tendencies — Heredi- 
tary Predisposition — Prognosis — Statistics — Age — Sex — Condi- 
tion of Life — Is Insanity on the Increase? — Exciting Causes — 
1. Moral — How to be avoided — 2. Physical — Prevention of the 
Recurrence of InsanhVv, 132 

LECTURE VII. 

The Symptoms of Insanity — The False Beliefs of the Insane — 
Definitions of Terms — Delusions — Their Rise — Varieties — Hal- 
lucinations — Their Seat — Hallucinations of Sight — Hearing — 
Smell— Taste— Touch, 153 

LECTURE VIII. 

The Acts of the Insane — Stripping Naked — Indecent Exposure — 
Fantastic Dress — Eating and Drinking — Habitual Drunkenness 
— Suicide — Self-mutilation — Talking to Self — Squandering Prop- 
erty — Homicide, for various Reasons — Pyromania — Erotomania 
— Kleptomania, 1T4 

LECTURE IX. 

The two Extremes of Insanity — Acute Delirium and Acute Primary 
Dementia — Early Symptoms of Derangement — Treatment — In- 
sanity with Depression — Treatment, Medical and Moral — Prog- 
nosis — Melancolie avec Stupeur, 192 

LECTURE X. 

Acute Melancholia — S3 r mptoms — Refusal of Food — Forcible Feed- 
ing by Various Methods — Drugs — Turkish Bath — Prognosis — 
Acute Primary Dementia — Symptoms — Diagnosis and Prognosis 
—Treatment, 213 



CONTENTS. Vll 



LECTURE XL 

PAGE 

Acute Delirious Mania — Diagnosis of Transitory Mania — How 
to Arrest it — Treatment of Prolonged Acute Delirium — Food — 
Nursing — Medicines — Baths — Purgatives — Prognosis — Diagno- 
sis, 



231 



LECTURE XII. 

Acute Mania — Symptoms — Treatment — Medicines — Prognosis — 
Terminations — Treatment of various Insane Patients — The In- 
sanity of Puberty — Masturbators — Puerperal Insanity — Insanity 
after a Blow — Coup de Soleil — Syphilis — Rheumatism — Epilepsy 
— Phthisis — Monomania, 251 

LECTURE XIII. 

General Paralysis of the Insane — Discovery of the Disease — Three 
Stages — First Stage — Alteration — Second Stage — Alienation — 
Mental and Bodily Symptoms — Epileptiform Attacks — Termina- 
tions of Second Stage — Temporary Improvement and Apparent 
Recovery — Third Stage — Progressive Paralysis and Dementia — 
Sex and Age of Patients, 269 

LECTURE XIV. 

General Paralysis, continued — Diagnosis — Illustrative Cases — Dis- 
eases simulating General Paralysis — Prognosis — Treatment — 
Post-mortem Appearance — Patholog}', 287 

LECTURE XY. 

Of Patients whose Insanity is doubtful — Insanity without Delu- 
sions — Are Delusions the Test of Insanity? — On Moral Insanity, 
so called — Dr. Prichard — His Illustrative Cases considered — 
Intellectual Defect in the Morally Insane — Moral Insanity in 
connection with Epilepsy and Old Age — Emotional Insanity — 
Prognosis and Treatment — On the so-called Legal Test, the 
Knowledge of Right and Wrong, 305 

LECTURE XYI. 

Impulsive Insanity — Characterized by Criminal Acts — Explanation 
of the Impulse — Rules for Diagnosis — Other Symptoms of In- 



Vlll CONTENTS. 

PAGE 

sanity usually discoverable — Weak-minded or Imbecile Patients 
— Characteristics — Cases — Demented Patients — Chief Defects — 
Cases, 32? 

LECTURE XYIL 

Terminations of Insanity — Liability of Recurrence — Recovery 
often Imperfect — How recognizable — Release of Dangerous Pa- 
tients to be refused — Concealed Insanity — A Trial to be advised 
— Recurring Insanity — Lucid Intervals — Recoveries numerous — 
Chance of Life — Causes of Death — Diagnosis of Bodily Disease 
— Care of the Chronic Insane, 349 

LECTURE XVIII. 

General Remarks on Treatment — Importance of Early Treatment 
to be urged by Family Practitioner — Restraint to be advised 
when necessary — Objections of Friends to be met — Use of an 
Asylum — Attendants — Delusions, how to be met — Asylums not 
necessaiy for all the Insane — On the Choice of an Asylum — 
Feigned Insanity — Hints for Detection — The Odor of the In- 
sane, 3?3 

LECTURE XIX. 

The Law of Lunacy — Private Patients — Order and Certificates — 
Single Patients — Notice of Discharge or Death — Leave of Ab- 
sence — Order of Transfer — Pauper Patients — The Property of 
Patients — Commission of Lunacy, 393 

LECTURE XX. 

On the Examination of Patients — Two Things to be considered — 
On Gaining Access to a Patient — On Estimating Doubtful In- 
sanity — Information to be Sifted — Yisit to a Patient — Conver- 
sation — Appearance — Alleged Delusions — On Patients who have 
no Delusions — On the Examination of Imbeciles and the De- 
mented — Conclusion, . 416 

APPENDIX. 
Laws of the several States respecting the Confinement of the In- 



sane. 



441 



Henry C. Lea's Publications — (Am. Journ. Med. Sciences). 3 

"Todd and Bowman's Physiology," "West on Children," "Malgaigne's Surgery," 
&c. &c. And with January, 1871, is commenced the valuable practical treatise of M. 
P. Guersant on the Surgical Diseases of Children, translated by R. J. Dunglison, 
M. D., rendering this a very eligible period for the commencement of new subscriptions. 
As stated above, the subscription price of the "Medical News and Library" is 
One Dollar per annum in advance ; and it is furnished without charge to all advance 
paying subscribers to the "American Journal op the Medical Sciences." 

ni. 
THE HALF-YEARLY ABSTRACT OF THE MEDICAL SCIENCES 

is issued in half-yearly volumes, which will be delivered to subscribers about the first 
of February, and first of August. Each volume contains about 300 closely printed 
octavo pages, making about six hundred pages per annum. 

"Banking's Abstract" has now been published in England regularly for more than 
twenty years, and has acquired the highest reputation for the ability and industry 
with which the essence of medical literature is condensed into its pages. It pur- 
ports to be "A Digest of British and Continental Medicine, and of the Progress of 
Medicine and the Collateral Sciences," and it is even more than this, for America is 
largely represented in its pages. It draws its material not only from all the leading 
American, British, and Continental journals, but also from the medical works and 
treatises issued during the preceding six months, thus giving a complete digest of 
medical progress. Each article is carefully condensed, so as to present its substance 
in the smallest possible compass, thus affording space for the very large amount of infor- 
mation laid before its readers. The volumes of 1870, for instance, have contained 

FORTY-THREE ARTICLES ON GENERAL QUESTIONS IN MEDICINE. 

NINETY-FIVE ARTICLES ON SPECIAL QUESTIONS IN MEDICINE. 

TWENTY-THREE ARTICLES ON FORENSIC MEDICINE. 

NINETY-NINE ARTICLES ON THERAPEUTICS. 

FORTY-FOUR ARTICLES ON GENERAL QUESTIONS IN SURGERY. 

ONE HUNDRED AND FIFTY-SIX ARTICLES ON SPECIAL QUESTIONS IN SURGERY 

NINETY-EIGHT ARTICLES ON MIDWIFERY AND DISEASES OF WOMEN AND CHILDREN 

TWO ARTICLES IN APPENDIX. 

Making in all over five hundred and fifty articles in a single year. Each volume, 
moreover, is systematically arranged, with an elaborate Table of Contents and a very 
full Index, thus facilitating the researches of the reader in pursuit of particular sub- 
jects, and enabling him to refer without loss of time to the vast amount of information 
contained in its pages. 

The subscription price of the "Abstract," mailed free of postage, is Two 
Dollars and a Half per annum, payable in advance. Single volumes, $1 50 each. 

As stated above, however, it will be supplied in conjunction with the "American 
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For this small sum the subscriber will therefore receive three periodicals costing 
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In this effort to bring so large an amount of practical information within the reach 
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be sustained in the endeavor to permanently establish medical periodical literature on 
a footing of cheapness never heretofore attempted. 

Any gentleman who will remit the amount for two subscriptions for 1871, one of 
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* # * Gentlemen desiring to avail themselves of the advantages thus offered will do 
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HENRY 0. LEA, 

Nos. 706 and 708 Sansom St., Philadelphia, Fa. 



Henry C. Lea's Publications — {Dictionaries). 



JJUNGLISON (ROBLEF), 31. D., 

Professor of Instittttes of Medicine in Jefferson Medical College, Philadelphia. 

MEDICAL LEXICON; A Dictionary of Medical Science: Con- 
taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
Pathology, Hygiene. Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae for 
Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of 
the Terms, and the French and other Synonymes ; so as to constitute a French as well as 
English Medical Lexicon. Thoroughly Revised, and very greatly Modified and Augmented. 
In one very large and handsome royal octavo volume of 1048 double-columned pages, in 
small type; strongly done up in extra cloth, $6 00 ; leather, raised bands, $6 75. 
The object of the author from the outset has not been to make the work a mere lexicon or 
dictionary of terms, but to afford, under each, a condensed view of its various medical relations, 
and thus to render the work an epitome of the existing condition of medical science. Starting 
with this view, the immense demand which has existed for the work has enabled him, in repeated 
revisions, to augment its completeness and usefulness, until at length it has attained the position 
of a recognized and standard authority wherever the language is spoken. The mechanical exe- 
eution of this edition will be found greatly superior to that of previous impressions. By enlarging 
the size of the volume to a royal octavo, and by the employment of a small but clear type, on 
extra fine paper, the additions have been incorporated without materially increasing the bulk of 
the volume, and the matter of two or three ordinary octavos has been compressed into the space 
of one not unhandy for consultation and reference. 

It is undoubtedly the most complete and useful 
medical dictionary hitherto published iu this country. 
— Chicago Med. Examiner, February, 1S65. 

What we take to be decidedly the best medical die- 



It would be a work of supererogation to bestow a 
word of praise upon this Lexicon. We can only 
wonder at the labor expended, for whenever we refer 
to its pages for information we are seldom disap- 
pointed in finding all we desire, whether it be in ac- 
centuation, etymology, or definition of terms. — New 
York Medical Journal, November, 1865. 

It would be mere waste of words in us to express 
our admiration of a work which is so universally 
and deservedly appreciated. The most admirable 
work of its kind in the English language. As a book 
of reference it is invaluable to the medical practi- 
tioner, and in every instance that we have turned 
over its pages for information we have been charmed 
by the clearness of language and the accuracy of 
detail with which each abounds. We can most cor- 
dially and confidently commend it to our readers. — 
Glasgow Medical Journal, January, 1866. 

A work to which there is no equal in the English 
language.— Edinburgh Medical Journal. 

It is something more than a dictionary, and some- 
thing less than an encyclopedia. This edition of the 
well-known work is a great improvement on its pre- 
decessors. The book is one of the very few of which 
it may be said with truth that every medical man 
should possess it.— London Medical Times, Aug. 26, 
1865. 

Few works of the class exhibit a grander monument 
of patient research and of scientific lore. The extent 
of the sale of this lexicon is sufficient to testify to its 
usefulness, and to the great service conferred by Dr. 
Robley Dunglison on tbe profession, and indeed on 
others, by its issue.— London Lancet, May 13, 1865. 

The old edition, which is now superseded by the 
new, has been universally looked upon by the medi- 
cal profession as a work of immense research and 
great value. The new has increased usefulness ; for 
medicine, in all its branches, has been making such 
progress that many new terms and subjects have re- 
cently been introd-iced : all of which may be found 
fully defined in the present edition. We know of no 
other dictionary in the English language that can 
bear a comparison with it in point of completeness of 
subjects and accuracy of statement.— N. Y. Drug- 
gists' Circular, 1865. 

For many years Dunglison's Dictionary has been 
the standard book of reference with most practition- 
ers in this country, and we can certainly commend 
this work to the renewed confidence and regard of 
our readers. — Cincinnati Lancet, April, 1865.. 



tionary in the English language. The present edition 
is brought fully up to the advanced state of science. 
For many a long year "Dunglison" has been at our 
elbow, a constant companion and friend, and we 
greet him in his replenished and improved form with 
especial satisfaction. — Pacific Med. and Surg. Jour- 
nal, June 27, 1865. 

This is, perhaps, the book of all others which the 
physician or surgeon should have on his shelves. It 
is more needed at the present day than a few years 
back. — Canada Med. Journal, July, 1865. 

It deservedly stands at the head, and cannot be 
surpassed in excellence. — Buffalo Med. and Surg. 
Journal, April, 1865. 

We can sincerely commend Dr. Dunglison's work 
as most thorough, scientific, and accurate. • We have 
tested it by searching its pages for new terms, which 
have abounded so much of late in medical nomen- 
clature, and our search has been successful in every 
instance. We have been particularly struck with the 
fulness of the synonymy and the accuracy of the de- 
rivation of words. It is as necessary a work to every 
enlightened physician as Worcester's English Dic- 
tionary is to every one who would keep up his know- 
ledge of the English tongue to the standard of the 
present day. It is, to our mind, the most complete 
work of the kind with which we are acquainted. — 
Boston Med. and Surg. Journal, June 22, 1865. 

We are free to confess that we know of no medical 
dictionary more complete; no one better, if so well 
adapted for the use of the studeat; no one that may 
be consulted with more satisfaction by the medical 
practitioner. — Am. Jour. Med. Sciences, April, 1865. 

The value of the present edition has been greatly 
enhanced by the introduction of new subjects and 
terms, and a more complete etymology and accentua- 
tion, which renders the work not only satisfactory 
and desirable, but indispensable to the physician. — 
Chicago Med. Journal, April, 1865. 

No intelligent member of the profession can or will 
be without it. — St. Louis Med. and Surg. Journal, 
April, 1S65. 

It has the rare merit that it certainly has no rival 
in the English language for accuracy and extent of 
references. — London Medical Gazette. 



TTOBLYN {RICHARD D.), M.D. 

A DICTIONARY GF THE TERMS USED IN MEDICINE AND 

THE COLLATERAL SCIENCES. A new American edition, revised, with numerous 
additiens, by Isaac Hays, M.D., Editor of the "American Journal of the Medical 
Sciences." In one large royal 12mo. volume of over 500 double-columned pages; extra 
cloth, $1 50 ; leather, $2 00. 
It is the best book of definitions we have, and ougkt always to be upon the student's table.— Southern 
Med. and Surg. Journal. 



Henry C. Lea's Publications — (Manuals). 



jaEILL {JOHN), M.I)., and &MITH [FRANCIS G.), M.D., 

"*- Prof, of the Institutes of Medicine in the Univ. of Penna. 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS 

BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A 
new edition, revised and improved. In one very large and handsomely printed royal 12mo. 
volume, of about one thousand pages, with 374 wood cuts, extra cloth, $4; strongly bound 
in leather, with raised bands, $4 75. 
The Compend of Drs. Neill and Smith is incompara- | cious facts treasured up iu this little volume. A com 



bly the most valuable work of its class ever published 
in this country- Attempts have been made in various 
quarters to squeeze Anatomy, Physiology, Surgery, 
the Practice of Medicine, Obstetrics, Materia Medica, 
and Chemistry into a single manual; but the opera- 
tion has signally failed in the hands of all up to the 
advent of" Neill and Smith's" volume, which is quite 
a miracle of success. The outlines of the whole are 
admirably drawn and illustrated; and the authors 
are eminently entitled to the grateful consideration 
of the student of every class.-»-iv". 0. Med. and Surg. 
Journal. 

There are but few students or practitioners of me- 
dicine unacquainted with the former editions of this 
anassuming though highly instructive work. The 
whole science of medicine appears to have been sifted, 
as the gold-bearing sands of El Dorado, and the pre- 



plete portable library so condensed that the student 
may make it his constant pocket companion. — West- 
ern Lancet. 

In the rapid course of lectures, where work for the 
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mination, a compend is not only valuable, but it is 
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of the kind that we know of. Of course it is useless 
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there is a class to whom we very sincerely commend 
this cheap book as worth its weight in silver — tkat 
class is the graduates in medicine of more than ten 
years' standing, who have not studied medieine 
since. They will perhaps find out from it that the 
science is not exactly now what it was when they 
left it off.— The Stethoscope. 



TJARTSHORNE [HENRY), 31 D., 

Professor of Hygiene in the University of Pennsylvania. 

A CONSPECTUS OF THE MEDICAL SCIENCES; containing 

Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
Surgery, and Obstetrics. In one large royal 12mo. volume of 1000 closely printed pages, 
with over 300 illustrations on wood, extra cloth, $4 50; leather, raised bands, $5 25. 
(Jvst Issued.) 
The ability of the author, and his practical skill in condensation, give assurance that this 
work will prove valuable not only to the student preparing for examination, but also to the prac- 
titioner desirous of obtaining within a moderate compass, a view of the existing condition of the 
various departments of science connected with medicine. 

less valuable to the beginner. Every medical student 
who desires a reliable refresher to his memory when 
the pressure of lectures and other college work crowd* 
to prevent him from having an opportunity to drink 
deeper in the larger works, will find this one of the 
greatest utility. It is thoroughly trustworthy from 
beginning to end ; and as we have before intimated, 
a remarkably truthful outline sketch of the present 
state of medical science. We could hardly expect it 
should be otherwise, however, under the charge of 
such a thorough medical scholar as the author has 
already proved himself to be. — N. York Med. Record, 
March 15, 1869. 



This work is a remarkably complete one in its way, 
and comes nearer to our idea of what a Conspectus 
should be than any we have yet seen. Prof. Harts- 
home, with a commendable forethought, intrusted 
the preparation of many of the chapters on special 
subjects to experts, reserving only anatomy, physio- 
logy, and practice of medicine to himself. As a result 
we have every department worked up to the latest 
date and in a- refreshingly concise and lucid manner. 
There are an immense amount of illustrations scat- 
tered throughout the work, and although they have 
often been seen before in the various works upon gen- 
eral and special subjects, yet they will be none the 



TUDLOW [J.L.), M.D. 
A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 

Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and 
Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
and greatly extended and enlarged. With 870 illustrations. In one handsome royal 
12mo. volume of 816 large pages, extra cloth, $3 25; leather, $3 75. 
The arrangement of this volume in the form of question and answer renders it especially suit- 
able for the office examination of students, and for those preparing for graduation. 



rTANNER [THOMAS HA WKES), M. D., $c. 

A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 
NOSIS. Third American from the Second London Edition. Revised and Enlarged by 
Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, 
Ac. In one neat volume small 12mo., of about 375 pages, extra cloth. $150. (Just Issmd.) 
This favorite little work has remained out of print for some years in consequence of the pressing 
engagements which have prevented the author from giving it the thorough revision which it re- 
quired. The great advance which has taken place of late in the means and appliances for 
observation and diagnosis has necessitated a very considerable enlargement of the work, so that 
it now contains about one-half more matter than the last edition. The Laryngoscope, Ophthalmo- 
scope, Sphygmograph, and Thermometer have received special attention. The chapter on the 
diagnostic indications afforded by th* Urine has been much enlarged, and a section has been 
inserted on the administration of Chloroform. Special attention has been given to the medieal 
anatomy of regions and organs, and much has been introduced relative to pericardial, endocardial, 
abdominal, and cerebro-spinal diseases. On every subject coming within its scope such additions 
have been made as seemed essential to bring the book on a level with the most advanced condi- 
tion of medical knowledge ; and it is hoped that it will continue to merit the very great ftivor 
with which it has hitherto been received. 



Henry C. Lea's Publications — (Anatomy). 



QRAY {HENRY), F.R.S., 

Lecturer on Anatomy at St. George's Hospital, London. 

ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by 

H. V. Cakter, M. D., late Demonstrator on Anatomy at St. George's Hospital ; the Dissec- 
tions jointly by the Author and Dr. Carter. A new American, from the fifth enlarged 
and improved London edition. In one magnificent imperial octavo volume, of nearly 900 
pages, with 465 large and elaborate engravings on wood. Price in extra cloth, $6 00 ; 
leather, raised bands, $7 00. (Just Issued.) 
The author has endeavored in this work to cover a more extended range of subjects than is cus- 
tomary in the ordinary text-books, by giving not only the details necessary for the student, but 
also the application of those details in the practice of medicine and surgery, thus rendering it both 
a guide for the learner, and an admirable work of reference for the active practitioner. The en- 
gravings form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in place of 
figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
refresh the memory of those who may find in the exigencies of practice* the necessity of recalling 
the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with 
a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
essential use to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 

Notwithstanding its exceedingly low price, the work will be found, in every detail of mechanical 
execution, one of the handsomest that has yet been offered to the American profession ; while the 
careful scrutiny of a competent anatomist has relieved it of whatever typographical errors existed 
in the English edition. A few notices of previous editions are subjoined. 

Thus it is that book after book makes the labor of 
the student easier than before, amd since we have 
seen Blanchard & Lea's new edition of Gray's Ana- 



tomy, certainly the finest work of the kind now ex- 
tant, we would fain hope that the bugbear of medical 
students will lose half its horrors, and this necessary 
foundation of physiological science will be much fa- 
cilitated and advanced. — N. O. Med. News. 

The various points illustrated are marked directly 
on the structure; that is, whether it be muscle, pro- 
cess, artery, nerve, valve, etc. etc. — we say each point 
is distinctly marked by lettered engravings, so that 
the student perceives at once each point descrihed as 
readily as if pointed out on the subject by the de- 
monstrator. Most of the illustrations are thus ren- 
dered exceedingly satisfactory, and to the physician 
they serve to refresh the memory with great readiness 



and with scarce a reference to the printed text. The 
surgical application of the various regions is also pre- 
sented with force and clearness, impressing upon the' 
student at each step of his research all the important 
relations of the structure demonstrated. — Cincinnati 
Lancet. 

This is, we believe, the handsomest book on Ana- 
tomy as yet published in our language, and bids fair 
to become in a short time the standard text-book of 
our colleges and studies. Students and practitioners 
will alike appreciate this book. We predict for it a 
bright career, and are fully prepared to endorse the 
statement of the London Lancet, that "We are not 
acquainted with any work in any language which 
can take equal rank with the one before us." Paper, 
printing, binding, all are excellent, and we feel that 
a grateful profession will not allow the publishers to 
go unrewarded. — Nashville Med. and Surg. Journal. 



s 



MITH {HENRY E.), M.D., and JJORNER { WILLIAM E.), M.D., 

Prof, of Surgery in the Univ. of Penna., Sec. Late Prof, of Anatomy in the Univ. ofPenna., Ac. 

AN ANATOMICAL ATLAS, illustrative of the Structure of the 

Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred 

and fifty beautiful figures. $4 50. 
The plan of this Atlas, which renders it so pecu- I the kind that has yet appeared; and we must add,, 
liarly convenient for the student, and its superb ar- | the very beautiful manner in which it is "got up " 
tistical execution, have been already pointed out. We is so creditable to the country as to be flattering to 
must congratulate the student upon the completion our national pride. — American MedicalJournal. 
of this Atlas, as it is the most convenient work of I 



TTARTSHORNE {HENRY), M.D., 

Professor of Hygiene, etc., in the University of Pennsylvania. 

A HAND-BOOK OF HUMAN ANATOMY AND PHYSIOLOGY, 

for the use of Students, with 176 illustrations. In one volume, royal 12mo. of 312 pages ; 
extra cloth, $1 75. (Jtist Issued.) 



OHARPEY ( WILLIAM), M.D., and Q UAIN {JONES £ RICHARD). 
HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph 

Leidv, M.D., Professor of Anatomy in the University of Pennsylvania. Complete in two 
large octavo volumes, of about 1300 pages, with 511 illustrations; extra cloth, $6 00. 
The very low price of this standard wOrk, and its completeness in all departments of the subject, 
should command for it a place in the library of all anatomical students. 



ALLEN {J. M.), M.D. 
THE PRACTICAL ANATOMIST; or, The Student's Guide in the 

Dissecting Room. With 266 illustrations. In one very handsome royal 12mo. volume, 
of over 600 pages; extra cloth, $2 00. 
One of the most useful works upon the subject ever written. — Medical Examiner. 



Henry C. Lea's Publications — (Anatomy). 7 

WILSON [ERASMUS), F.R.S. 

f A SYSTEM OF HUMAN ANATOMY, General and Special. A 

new and revised American, from the last and enlarged English edition. Edited by VV. H. Go- 
brecht, M. D., Professor of General and Surgical Anatomy in the Medical College of Ohio. 
Illustrated with three hundred and ninety-seven engravings on wood. In one large and 
handsome octavo volume, of over 600 large pages; extra cloth, $4 00; leather, $5 00. 
The publisher trusts that the well-earned reputation of this long-established favorite will be 
more than maintained by the present edition. Besides a very thorough revision by the author, it 
has been most carefully examined by the editor, and the efforts of both have been directed to in- 
troducing everything which increased experience in its use has suggested as desirable to render it 
a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- 
tomy. The amount of additions which it has thus received may be estimated from the fact that 
th« present edition contains over one-fourth more matter than the last, rendering a smaller type 
and an enlarged page requisite to keep the volume within a convenient size. The author has not 
only thus added largely to the work, but he has also made alterations throughout, wherever there 
appeared the opportunity of improving the arrangement or style, so as to present every fact in its 
most appropriate manner, and to render the whole as clear and intelligible as possible. The editor 
has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased 
the number of illustrations, of which there are about one hundred and fifty more in this edition 
than in the last, thus bringing distinctly before the eye of the student everything of interest or 
importance. 

JJEATH {CHRISTOPHER), F. R. C. S., 

-*--*- Teacher of Operative Surgery in University College, London. 

PRACTICAL ANATOMY: A Manual of Dissections. From the 

Second revised and improved London edition. Edited, with additions, by W. W. Keen, 
M.D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. 
In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Extra cloth, 
$3 50; leather, $4 00. {Just Issued.) 

Numerous as the published guides for dissectors dium ; it is full and yet concise, while its directions for 
have been, scarcely any seem to fulfil all the require- the use of the kuife are judiciously woven into the 
ments of the student. Valuable anatomical informa- general mass of anatomical details. The additions 
tion is often sacrificed to lengthy discussions on nice- | made by the American editor bear the evidences of 
ties of incisions and rules for delicate processes of l manipulation by an experienced anatomist, who is 
disintegration of the cadaver ; while occasionally the j thoroughly alive to the needs of the student at thedis 
"Dissectors," as these works are familiarly called, secting table. They are profuse, practical, aud appro- 
are swollen into the ponderous dimensions of system- : priate The volume occupies from five to six hundred 
atic treatisesondescriptiveanatomy. The work before pages, and is a beautiful specimen of typographical 
us seems to have successfully aimed at a happy me- execution.— Am. Journ. of Med. Set, Oct. 1870. 



ITODGES, {RICHARD M.), M.I)., 

■*■-*■ Late Demonstrator of Anatomy in the Medical Department of Harvard University. 

PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In 

one neat royal 12mo. volume, half-bound, $2 00. 
The object of this work is to present to the anatomical student a clear and concise description 
of that which he is expected to observe in an ordinary course of dissections. The author has 
endeavored to omit unnecessary details, and to present the subject in the form which many years' 
experience has shown him to be the most convenient and intelligible to the student. In the 
revision of the present edition, he has sedulously labored to render the volume more worthy of 
the favor with which it has heretofore been received. 



JjJACLISE {JOSEPH). 

SURGICAL ANATOMY. By Joseph Macltse, Surgeon. In one 

volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best 
style and beautifully colored, containing 190 figures, many of them the size of life; together 
with copious explanatory letter-press. Strongly and handsomely bound in extra cloth. 
Price $14 00. 
As no complete work of the kind has heretofore been published in the English language, the 
present volume will supply a want long felt in this country of an accurate and comprehensive 
Atlas of Surgical Anatomy, to which the student and practitioner can at all times refer to ascer- 
tain the exact relative positions of the various portions of the human frame towards each other 
and to the surface, as well as their abnormal deviations. Notwithstanding the large size, beauty 
and finish of the very numerous illustrations, it will be observed that the price is so low as to 
place it within the reach of all members of the profession. 

We know of no work on surgical anatomy which ( refreshed by those clear and distinct dissections, 

which every one must appreciate who has a particle 
of enthusiasm. The English medical press has quite 
exhausted the words of praise, in recommending this 
admirable treatise. Those who have any curiosity 
to gratify, in reference to the perfectibility of the 
lithographic art in delineating the complex mechan- 
ism of the human body, are invited to examine our 
specimen copy. If anything will induce surgeons 
and students to patronize a book of such rare value 
and everyday importance to them, it will be a survey 
the operator is shown every vessel and nerve where , of the artistical skill exhibited in these fac-similes of 
an operation is contemplated, the exact anatomist is | nature.— Boston Med. and Surg. Journal. 

HORNER'S SPECIAL ANATOMY AND HISTOLOGY. I In 2 vols. Svo., of over 1000 pages, with more than 
Eighth edition, extensively revised and modified. | 300 wood-cuts ; extra cloth, $6 00. 



can compete with it. — Lancet. 

The work of Maclise on surgical anatomy is of the 
highest value. In some respects it is the best publi- 
cation of its kind we have seen, and is worthy of a 
place in the libiary of any medical man, while the 
student could scarcely make a better investment than 
this.— The Western Journal of Medicine and Surgery. 

No 6uch lithographic illustrations of surgical re- 
gions have hitherto, we think, been given. While 



Henry C. Lea's Publications— {Physiology). 



MARSHALL {JOHN), F. R. S., 

JJJL Professor of Surgery in University College, London, &c. 

OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. 

With Additions by Francis Gurnet Smith, M. D., Professor of the Institutes of Medi- 
cine in the University of Pennsylvania, &c. With numerous illustrations. In one large 
and handsome octavo volume, of 1026 pages, extra cloth, $6 50 : leather, raised bands 
$7 50. (Just Issued.) 



In fact, in every respect, Mr. Marshall has present- 
ed us with a most complete, reliahle, and scientific 
■work, and we feel that it is worthy our warmest 
commendation. — St. Louis Med. Reporter, Jan. 1869. 

This is an elahorate and carefully prepared digest 
of human and comparative physiology, designed for 
the use of general readers, but more especially ser- 
viceable to the student of medicine. Its style is con- 
cise, clear, and scholarly ; its order perspicuous and 
exact, and its range of topics extended. The author 
and his American editor have been careful to bring 
to the illustration of the subject the important disco- 
veries of modern science in the various cognate de- 
partments of investigation. This is especially visible 
in the variety of interesting information derived from 
the departments of chemistry and physics. The great 
amount and variety of matter contained in the work 
is strikingly illustrated by turning over the copious 
index, covering twenty-four closely printed pages in 
double columns. — Silliman's Journal, Jan. 1869. 

We doubt if there is in the English language any 
compend of physiology more useful to the student 
than this work.— St. Louis Med. and Surg. Journal, 
Jan. 1S69. 

It quite fulfils, in our opinion, the author's design 
of making it truly educational in its character — which 
is, perhaps, the highest commendation that can be 
asked. — Am. Journ. Med. Sciences, Jan. 1869. 

We may now congratulate him on having com- 
pleted the latest as well as the best summary of mod- 



ern physiological science, both human and compara- 
tive, with which we are acquainted. To speak of 
this work in the terms ordinarily used on such occa- 
sions would not be agreeable to ourselves, and would 
fail to do justice to its author. To write such a book 
requires a varied and wide range of knowledge, con- 
siderable power of analysis, correct judgment, skill 
in arrangement, and conscientious spirit. It must 
have entailed great labor, but now that the task has 
been fulfilled, the book will prove not only invaluable 
to the student of medicine and surgery, but service- 
able to all candidates in natural science examinations, 
to teachers in schools, and to the lover of nature gene- 
rally. In conclusion, we can only express the con- 
viction that the merits of the work will command for 
it that success which the ability and vast labor dis- 
played in its production so well deserve. — London 
Lancet, Feb. 22, 1868. 

If the possession of knowledge, and peculiar apti- 
tude and skill in expounding it, qualify a man to 
write an educational work, Mr. Marshall's treatise 
might be reviewed favorably without even opening 
the covers. There are few, if any, more accomplished 
anatomists and physiologists than the distinguished 
professor of surgery at University College ; and he 
has long enjoyed the highest reputation as a teacher 
of physiology, possessing remarkable powers of clear 
exposition and graphic illustration. We.bave rarely 
the pleasure of being able to recommend'a text-book 
so unreservedly as this.— British Med. Journal, Jan. 
25, 1868. 



flARPENTER {WILLIAM B.), M.D., F.R.S., 

^S Examiner in Physiology and Comparative Anatomy in the University of London. 

PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- 

cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new 
American from the last and revised London edition. With nearly three hundred illustrations. 
Edited, with additions, by Francis Gtjrney Smith, M. D., Professor of the Institutes of 
Medicine in the University of Pennsylvania, Ac. In one very large and beautiful octavo 
volume, of about 900 large pages, handsomely printed j extra cloth, $5 50 j leather, raised 
bands, $6 50. 



With Dr. Smith, we confidently believe "that the 
present will more than sustain the enviable reputa- 
tion already attained by former editions, of being 
one of the.fullest and most complete treatises on the 
subject in the English language." We know of none 
from the pages of which a satisfactory knowledge of 
the physiology of the human organism can be as well 
obtained, none better adapted for the use of such as 
take up the study of physiology in its reference tof 
the institutes and practice of medicine. — Am. Jour. 
Med. Sciences. 



We doubt not it is destined to retain a strong hold 
on public favor, and remain the favorite text-book in 
our colleges. — Virginia Medical Journal. 

The above is the title of what is emphatically the 
great work on physiology; and we are conscious that 
it would be a useless effort to attempt to add any- 
thing to the reputation of this invaluable work, and 
can only say to all with whom our opinion has any 
influence, that it is our authority. — Atlanta Med. 
Journal. 



JDT THE SAME AUTHOR. 

PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Ameri- 

can, from the Fourth and Revised London Edition. In one large and handsome octavo 
volume, with over three hundred beautiful illustrations Pp.752. Extra cloth, $5 00. 
As a complete and condensed treatise on its extended and important subject, this work becomes 

a necessity to students of natural science, while the very low price at which it is offered places it 

within the reach of all. 



JTIRKES {WILLIAM SENHOTJSE), M.D. 

A MANUAL OF PHYSIOLOGY. A new American from the third 

and improved. London edition. With two hundred illustrations. In one large and hand- 
some royal 12mo. volume. Pp. 586. Extra cloth, $2 25 ; leather, $2 75. 
It is at once convenient in size, comprehensive in lent guide in the study of physiology in its most ad- 
design, and concise in statement, and altogether well vanced and perfect form. The author has shown 
adapted for the purpose designed.— St. Louis Med. himself capable of giving details sufficiently ample 
and Surg. Journal. in a condensed and concentrated shape, on a science 

in which it is necessary at once to be correct and not 
The physiological reader will find it a moat excel- j lengthened —Edinburgh Med. and Surg. Journal. 



Henry C. Lea's Publications— {Physiology). 



9 



fhALTON (J. C.), M. D., 

-*S Professor of Physiology in the College of Physicians and Surgeons, New York, &c. 

A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use 

of Students and Practitioners of Medicine. Fourth edition, revised, with nearly three hun- 
dred illustrations on wood. In one very beautiful octavo volume, of about 700 pages, extra 
eloth, $5 25 ; leather, $6 25. 

From the Preface to the New Edition. 
"The progress made by Physiology and the kindred Sciences during the last few years has re- 
quired, for the present edition of this work, a thorough and extensive revision. This progress 
has not consisted in any very striking single discoveries, nor in a decided revolution in any of 
the departments of Physiology ; but it has been marked by great activity of investigation in a 
multitude of different directions, the combined results of which have not failed to impress a new 
character on many of the features of physiological knowledge. ... In the revision and 
correction of the present edition, the author has endeavored to incorporate all such improve- 
ments in physiological knowledge with the mass of the text in such a manner as not essentially 
to alter the structure and plan of the work, so far as they have been found adapted to the wants 
and convenience of the reader. . . . Several new illustrations are introduced, some of them 
as additions, others as improvements or corrections of the old. Although all parts of the book 
have received more or less complete revision, the greatest number of additions and changes were 
required in the Second Section, on the Physiology of the Nervous System." 



The advent of the first edition of Prof. Dalton's 
Physiology, about eight years ago, marked a new era 
in the study of physiology to the American student. 
Under Dalton's skilful management, physiological 
science threw off the long, loose, ungainly garments 
of probability and surmise, in which it had been ar- 
rayed by most artists, and came among us smiling 
and attractive, in the beautifully tinted and closely 
fitting dress of a demonstrated science. It was a 
stroke of genius, as well as a result of erudition and 
talent, that led Prof. Dalton to present to the world 
a work on physiology at once brief, pointed, and com- 
prehensive, and which exhibited plainly in letter and 
drawings the basis upon which the conclusions ar- 
rived at rested. It is no disparagement of the many 
excellent works on physiology, published prior to 
that of Dalton, to say that none of them, either in 
plan of arrangement or clearness of execution, could 
be compared with his for the use of students or gene- 
ral practitioners of medicine. For this purpose his 
book has no equal in the English language. — Western 
Journal of Medicine, Nov. 1867. 

A capital text-book in every way. We are, there- 
fore, glad to see it in its fourth edition. It has already 
been examined at full length in these columns, so that 
we need not now further advert to it beyond remark- 
ing that both revision and enlargement have been 
most judicious.— London Med. Times and Gazette, 
Oct. 19, 1867. 

No better proof of the value of this admirable 
work could be produced than the fact that it has al- 
ready reached a fourth edition in the short space of 
eight years. Possessing in an eminent degree the 



merits of clearness and condensation, and being fully 
brought up to the present level of Physiology, it is 
undoubtedly one of the most reliable text-books 
upon this science that could be placed in the hands 
of the medical student. — Am. Journal Med. Sciences, 
Oct. 1867. 

Prof. Dalton's work has such a well-established 
reputation that it does not stand in need of any re- 
'commendation. Ever since its first appearance it has 
become the highest authority in the English language ; 
and that it is able to maintain the enviable position 
which it has taken, the rapid exhaustion of the dif- 
ferent successive editions is sufficient evidence. The 
present edition, which is the fourth, has been tho- 
roughly revised, and enlarged by the incorporation 
of all the many important advances which have 
lately beeu made in this rapidly progressing science. 
—N. Y. Med. Record, Oct. 15, 1867. 

As it stands, we esteem it the very best of the phy- 
siological text-books for the student, and the most 
concise reference and guide-book for the practitioner. 
—N. Y. Med. Journal, Oct. 1667. 

The present edition of this now standard work fully 
sustains the high reputation of its accomplished au- 
thor. It is not merely a reprint, but has been faith- 
fully revised, and enriched by such additions as the 
progress of physiology has rendered desirable Taken 
as a whole, it is unquestionably the most reliable and 
useful treatise on the subject that has been issued 
from the American press. — Chicago Med. Journal, 
Sept. 1867. 



fkUNGLISON (ROBLEF). 31. D., 

■U Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and 

extensively modified and enlarged, with five hundred and thirty-two illustrations. In two 
large and handsomely printed octavo volumes of about 1500 pages, extra cloth. $7 00. 



J EHMANN (C. G.). 

PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- 
tion by George E Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of 
Chemistry in the Medical Department of the University of Pennsylvania, with illustrations 
selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Com- 
plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two 
hundred illustrations, extra cloth. $6 00. 

DF THE SAME AUTHOR. 

MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the 

German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory 
Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsyl- 
vania. With illustrations on wood. In one very handsome octavo volume of 336 pages, 
extra cloth. $2 25. 

rnODD {ROBERT B.), M.D. F.R.S., and gOWMAN (TT.), F.R.S. 
THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF 

MAN. With about three hundred large and beautiful illustrations on wood. Complete in 
one large octavo volume of 950 pages, extra cloth. Price $4 75. 



10 



Henry C. Lea's Publications — (Chemistry). 



T>RANDE ( WM. T.), D. C.L., and fTAYLOR [ALFRED S.), M.D., F.R.S. 
CHEMISTRY. Second American edition, thoroughly revised by Dr. 

Taylor. In one handsome 8vo. volume of 764 pages, extra cloth, $5 00 ; leather, $6 00. 
From Dr. Taylor's Preface. 
"The revision of the second edition, in consequence of the death of my lamented colleague, 
has devolved entirely upon myself. Every chapter, and indeed every page, has been revised, 
and numerous additions made in all parts of the volume. These additions have been restricted 
chiefly to subjects having some practical interest, and they have been made as concise as possible, 
in order to keep the book within those limits which may retain for it the character of a Student's 
Manual " — London, June 29, 1867. 



A book that has already so established a reputa- 
tion, as has Brande and Taylor's Chemistry, can 
hardly need a notice, save to mention the additions 
and improvements of the edition. Doubtless the 
work will long remain a favorite text-book in the 
schools, as well as a convenient book of reference for 
ail.— N. Y. Medical Gazette, Oct. 12, 1867. 

For this reason we hail with delight the republica- 
tion, in a form which will meet with general approval 
and command public attention, of this really valua- 
ble standard work on chemistry — more particularly 
as it has been adapted with such care to the wants of 
the general public. The well known scholarship of 
its authors, and their extensive researches for many 
years in experimental chemistry, have been long ap- 
preciated in the scientific world, but in this work they 
have been careful to give the largest possible amount 
of information with the most sparing use of technical 
terms and phraseology, so as to furnish the reader, 
"whether a student of medicine, or a man of the 
world, with a plain introduction to the science and 
practice of chemistry." — Journal of Applied Chem- 
istry, Oct. 1867. 



This second American edition of an excellent trea- 
tise on chemical science is not a mere republication 
from the English press, but is a revision and en- 
largement of the original, under the supervision of 
the surviving author, Dr. Taylor. The favorable 
opinion expressed on the publication of the former 
edition of this work is fully sustained by the present 
revision, in which Dr. T. has increased the size of 
the volume, by an addition of sixty-eight pages. — Am. 
Journ. Med. Sciences, Oct. 1S67. 

The Handbook in Chemistry of the Student.— 
For clearness of language, accuracy of description, 
extent of information, and freedom from pedantry 
and mysticism, no other text-book comes into com- 
petition with it. — The Lancet. 

The authors set out with the definite purpose of 
writing a book which shall be intelligible to any 
educated man. Thus conceived, and worked out in 
the most sturdy, common-sense method, this book 
gives in the clearest and most summary method 
possible all the facts and doctrines of chemistry. — 
Medical Times. 



QDLING [WILLIAM), 

^S Lecturer on Chemistry, at St. Bartholomew's Hospital, &c. 

A COURSE OF PRACTICAL CHEMISTRY, arranged for the Use 

of Medical Students. With Illustrations. From the Fourth and Revised London Edition. 
In one neat royal 12mo. volume, extra cloth. $2. {Lately Issued.) 

As a work for the practitioner it cannot be excelled. 
It is written plainly and concisely, and gives in a very 
small compass the information required by the busy 



•practitioner. It is essentially a work for the physi- 
cian, and no one who purchases it will ever regret the 
outlay. In addition to all that is usually given in 
connection with inorganic chemistry, there are most 
valuable contributions to toxicology, animal and or- 



ganic chemistry, etc. The portions devoted to a dis- 
cussion of these subjects are very excellent. In no 
work can the physician find more that is valuable 
and reliable in regard to urine, bile, milk, bone, uri- 
nary calculi, tissue composition, etc. The work is 
small, reasonable in price, and well published. — 
Richmond and Louisville Med. Journal, Dec. 1869. 



J}OWMAN [JOHN E 

PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. 



M. D. 

Edited 

by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Fifth 
American, from the fourth and revised English Edition. In one neat volume, royal 12mo., 
pp. 351, with numerous illustrations, extra cloth. $2 25. (Now Ready.) 

The fourth edition of this invaluable text-book of which have come to light since the previous edition 

Medical Chemistry was published in England in Octo- was printed. The work is indispensable to every 

ber of the last year. The Editor has brought down student of medicine or enlightened practitioner. It 

the Handbook to that date, introducing, as far as was is printed in clear type, and the illustrations are 

compatible with the necessary conciseness of such a numerous and intelligible. — Boston Med. and Surg. 

work, all the valuable discoveries in the science Journal. 

T>Y THE SAME AUTHOR. 

INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING 

ANALYSIS. Fifth American, from the fifth and revised London edition. With numer- 
ous illustrations. In one neat vol., royal 12mo., extra cloth. $2 25. (Now Ready.) 



One of the most complete manuals that has for a 
long time been given to the medical student. — 
Athenaium. 

We regard it as realizing almost everything to be 
desired in an introduction to Practical Chemistry. 



It is by far the best adapted for the Chemical student 
of any that has yet fallen in our way. — British and 
Foreign Medico-Chirurgical Review. 

The best introductory work on the subject with 
which we are acquainted. — Edinburgh Monthly Jour. 



fiRAHAM [ THOMAS), F. R. S. 

^THE ELEMENTS OF INORGANIC CHEMISTRY, including the 

Applications of the Science in the Arts. New and much enlarged edition, by Henry 
Watts and Robert Bridges, M. D. Complete in one large and handsome ootavo volume, 
of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. 

$5 50. 

KNAPP'S TECHNOLOGY ; or Chemistry Applied to 1 very handsome octavo volumes, with 500 wood 
the Arts, and to Manufactures. With American engravings, extra cloth, $6 00. 
additions, by Prof. Walter K. Johnson. In two | 



Henry C. Lea's Publications — (Chemistry, Pharmacy, &c). 11 



vrOWNES {GEORGE), Ph. D. 



A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 

Practical. With one hundred and ninety-seven illustrations. A new American, from the 
tenth and revised London edition. Edited by Robert Bridges, M. D. In one large 
royal 12mo. volume, of about 850 pp ., extra cloth, $2 75 ; leather, S3 25. (Just Issued.) 
Some years having elapsed since the appearance of the last American edition, and several 
revisions having been made of the work in England during the interval, it will be found very 
greatly .altered, and enlarged by about two hundred and fifty pages, containing nearly one half 
more matter than before. The editors, Mr. Watts and Dr. Bence Jones, have labored sedulously 
to render it worthy in all respects of the very remarkable favor which it has thus far enjoyed, by 
incorporating* in it all the most recent investigations and discoveries, in so far as is compatible with 
its design as an elementary text-book. While its distinguishing characteristics have been pre- 
served, various portions have been rewritten, and especial pains have been taken with the 
department of Organic Chemistry in which late researches have accumulated so many new facts 
and have enabled the subject to be systematized and rendered intelligible in a manner formerly 
impossible. As only a few months have elapsed since the work thus passed through the hands 
of Mr. Watts and Dr. Bence Jones, but little has remained to be done by the American editor. 
Such additions as seemed advisable have however been made, and especial care has been taken 
to secure, by the closest scrutiny, the accuracy so essential in a work of this nature. 

Thus fully brought up to a level with the latest advances of science, and presented at a price 
within the reach of all, it is hoped that the work will maintain its position as the favorite text- 
book of the medical student. 

This work is so well known that it seems almost 
superfluous for us to speak about it. It has been a 
favorite text-book with medical students for years, 
and its popularity has in no respect diminished. 
Whenever we have been consulted by medical stu- 
dents, as has frequently occurred, what treatise on 
chemistry they should procure, we have always re- 
commended Fownes', for we regarded it as the best. 
There is no work that combines so many excellen- 
ces. It is of convenient size, not prolix, of plain 
perspicuous diction, contains all the most recent 
discoveries, and is of moderate price. — Cincinnati 
Med. Repertory, Aug. 1869. 

Large additions have. been made, especially in the 
department of organic chemistry, and we know of no 
other work that has greater clai*s on the physician, 
pharmaceutist, or student, than this. We cheerfully 
recommend it as the best text-book on elementary 
chemistry, and bespeak for it the careful attention 
of students of pharmacy. — Chicago Pharmacist, Aug. 
1869. 

The American reprint of the tenth revised and cor- 
rected English edition is now issued, and represents 
the present condition of the science. No comments 
are necessary to insure it a favorable reception at 
the hands of practitioners and students. — Boston 
Med. and Surg. Journal, Aug. 12, 1869. 

It will continue, as heretofore, to hold the first rank 
as a text-book for students of medicine — Chicago 
Med. Examiner, Aug. 1S69. 

This work, long the recoguized Manual of Chemistry, 
appears as a tenth edition, under the able editorship 
of Bence Jones and Henry Watts. The chapter on 



the General Principles of Chemical Philosophy, and 
the greater part of the organic chemistry, have been 
rewritten, and the whole work revised in accordance 
with the recent advances in chemical knowledge. It 
remains the standard text-book of chemistry. — Dub- 
lin Quarterly Journal, Feb. 1S69. 

There is probably not a student of chemistry in this 
country to whom the admirable manual of the late 
Professor Fownes is unknown It has achieved a 
success which we believe is entirely without a paral- 
lel among scientific text-books in our language. This 
success has arisen from the fact that there is no En- 
glish work on chemistry which combines so many 
excellences. Of convenient size, of attractive form, 
clear and concise in diction, well illustrated, and of 
moderate price, it would seem that every requisite 
for a student's hand-book has been attained. The 
ninth edition was published under the joint editor- 
ship of Dr. Bence Jones and Dr. Hofmann; the new 
one has been superintended through the press by Dr. 
Bence Jones and Mr. Henry Watts. It is not too 
much to say that it could not possibly have been in 
better hands. There is no one in England who can 
compare with Mr. Watts in experience as a compiler 
in chemical literature, and we have much pleasure 
in recording the fact that his reputation is well sus- 
tained by this, his last undertaking. — The Chemical 
News, Feb. 1669. 

Here is a new edition which has been long watched 
for by eager teachers of chemistry. In its new garb, 
and under the editorship of Mr. Watts, it has resumed 
its old place as the must successful of text-books. — 
Indian Medical Gazette, Jan. 1, 1869. 



[TTFIELD (JOHN), Ph.D., 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, dc. 

CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL; 

including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles 
of the Science, and their Application to Medicine and Pharmacy. In one handsome royal 
12mo. volume. (Nearly Ready.) 

I It is almost the ouly book from which the medical 
I student can work up the pharmacopceial chemistry 

required at his examinations. — Tlie Pliarmaceutical 

Journal 



It contains a most admirable digest of what is spe- 
cially needed hy the medical student in all that re- 
lates to practical chemistry, and constitutes for him 

a sound and useful text-book on the subject 

We commend it to the notice of every medical, as well 
as pharmaceutical, student. We only regret that we 
had not the book to depend upon in working up the 
subject of practical and pharmaceutical chemistry for 
the University of Loudon, for which it seems to us 
that it is exactly adapted. This is paying the book a 
high compliment. — The Lancet. 

Dr. Attfield's book is written in a clear and able 
manner; it is a work sui generis and without a rival ; 
it will be welcomed, we think, by every reader of the 
'Pharmacopoeia,' and is quite as well suited for the 
medical student as for the pharmacist. — The Chemi- 
C(d Neios 

A valuable guide to practical medical chemistry, 
and an admirable companion to the "British Phar- 
macopoeia " It is rare to find so many qualities com- 
bined, and quite curious to note how much valuable 
information fiuds a mutual interdependence.— Medi- 
cal Times and Gazette. 



At page 3d0 of the current volume of this journal, 
we remarked that " there is a sad dearth of [medical] 
students' text-bonks in chemistry." Dr. Attfield's 
volume, just published, is rather a new book thau a 
second edition of his previous work, and more nearly 
realizes our ideal than any book we have before seen 
on the subject. — The British Medical Journal. 

The introduction of new matter has not destroyed 
the original character of the work, as a treatise on 
pharmaceutical and medical chemistry, but has sim- 
ply extended the foundations of these special depart- 
ments of the science. — The Chemist and Druggist. 

We believe that this manual has been already 
adopted as the class-book by many of the professors 
in the public schools throughout the United Kingdom. 
. . . In pharmaceutical chemistry applied to the phar- 
macopoeia, we know of no rival. It is, therefore, par- 
ticularly suited to the medical student. — The Medical 
Press and Circular. 



12 Henry C. Lea's Publications — {Mat. Med. and Therapeutics). 



pARRlSH (ED WARD), 

Professor of Materia Mediea in the Philadelphia College of Pharmacy . 

A TREATISE ON PHARMACY. Designed as a Text-Book for the 

Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
Prescriptions. Third Edition, greatly improved. In one handsome octavo volume, of 850 
pages, with several hundred illustrations, extra cloth. $5 00. 
The immense amount of practical information condensed in this volume may be estimated from 
the fact that the Index contains about 4700 items. Under the head of Acids there are 312 refer- 
ences ; under Emplastrum, 36; Extracts, 159; Lozenges, 25; Mixtures, 55 ; Pills, 56; Syrups, 
131 ; Tinctures, 138 ; Unguentum, 57, <&c 



We have examined this large volume with a good 
deal of care, and find that the author has completely 
exhausted the subject upon which he treats ; a more 
complete work, we think, it would be impossible to 
find. To the student of pharmacy the work is indis- 
pensable ; indeed, so far as we know, it is the only one 
of its kind in existence, and even to the physician or 
medical student who can spare five dollars to pur- 
chase it, we feel su*re the practical information he 
will obtain will more than compensate him for the 
outlay. — Canada Med. Journal, Nov. 1864. 

The medical student and the practising physician 
will find the volume of inestimable worth for study 
and reference. — San Francisco Med. Press, July, 
1864. 

When we say that this book is in some respects 
the best which has been published on the subject in 
the English language for a great many years, we do 



not wish it to be understood as very extravagant 
praise. In truth, it is not so much the best as the 
only book. — The London Chemical News. 

An attempt to furnish anything like an analysis of 
Parrish's very valuable and elaborate Treatise on 
Practical Pharmacy would require more space than 
we have at our disposal. This, however, is not so 
much a matter of regret, inasmuch as it would be 
difficult to think of any point, however minute and 
apparently trivial, connected with the manipulation 
of pharmaceutic substances or appliances which has 
not been clearly and carefully discussed in this vol- 
ume. Want of space prevents our enlarging further 
on this valuable work, and we must conclude by a 
simple expression of our hearty appreciation of its 
merits. — Dublin Quarterly Jour, of Medical Science, 
August, 1864. 



OTILLE (ALFRED), 31. D., 

*D Professor of Theory and Practice of Medicine in the University of Penna. 

THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise 

on the Action and Uses of Medicinal Agents, including their Description and History. 
Third edition, revised and enlarged. In two large and handsome octavo volumes of about 
1700 pages, extra cloth, $10 ; leather, $12. 
Dr. Stille's splendid work on therapeutics and ma- 
teria mediea. — London Med. Times, April 8, 1865. 

Dr. Stills stands to-day one of the best and most 
honored representatives at home and abroad, of Ame- 



rican medicine ; and these volumes, a library in them 
selves, a treasure-house for every studious physician, 
assure his fame even had he done nothing more. — The 
Western Journal of Medicine, Dec. 1868. 

We regard this work as the best one on Materia 
Mediea in the English language, and as such it de- 
serves the favor it has received. — Am. Journ. Medi- 
cal Sciences, July 1868. 

We need not dwell on the merits of the third edition 
of this magnificently conceived work. It is the work 
on Materia Mediea, in which Therapeutics are prima- 
rily considered — the mere natural history of drugs 
being briefly disposed of. To medical practitioners 
this is a very valuable conception. It is wonderful 
how much of the riches of the literature of Materia 
Mediea has been condensed into this book. The refer- 
ences alone would make it worth possessing. But it 
is not a mere compilation. The writer exercises a 
good judgment of his own on the great doctrines and 
points of Therapeutics. For purposes of practice, 
Still6's book is almost unique as a repertory of in- 
formation, empirical and scientific, on the actions and 
uses of medicines. — London Lancet, Oct. 31, 1S68. 

Through the former editions, the professional world 
is well acquainted with this work. At home and 



abroad its reputation as a standard treatise on Materia 
Mediea is securely established. It is second to no 
work on the subject in the English tongue, and, in- 
deed, is decidedly superior, in some respects, to any 
other. — Pacific Med. and Surg. Journal, July, 1868. 

Stille's Therapeutics is incomparably the best work 
on the subject.— N. Y. Med. Gazette, Sept. 26, 1868. 

Dr. Stille's work is becoming the best known of any 
of our treatises on Materia Mediea. . . . One of the 
most valuable works in the language on the subjects 
of which it treats.— N. T. Med. Journal, Oct. 1868. 

The rapid exhaustion of two editions of Prof. Stille's 
scholarly work, and the consequent necessity for a 
third edition, is sufficient evidence of the high esti- 
mate placed upon it by the profession. It is no exag- 
geration to say that there is no superior work upon 
the subject in the English language. The present 
edition is fully up to the most recent advance in the 
science and art of therapeutics. — Leavenworth Medi- 
cal Herald, Aug. 1868. 

The work of Prof. Still6 has rapidly taken a high 
place in professional esteem, and to say that a third 
edition is demanded and now appears before as, suffi- 
ciently attests the firm position this treatise has made 
for itself. As a work of great research, and scholar- 
ship, it is safe to say we have nothing superior. It is 
exceedingly full, and the busy practitioner will find 
ample suggestions upon almost every important point 
of therapeutics. — Cincinnati Lancet, Aug. 1868. 



QRIFFITH (ROBERT E.), M.D. 

A UNIVERSAL FORMULARY, Containing the Methods of Pre- 
paring and Administering Officinal and other Medicines. The whole adapted to Physicians 
and Pharmaceutists. Second edition, thoroughly revised, with numerous additions, by 
Robert P. Thomas, M.D., Professor of Materia Mediea in the Philadelphia College of 
Pharmacy. In one large and handsome octavo volume of 650 pages, double-columns. 
Extra cloth, $4 00; leather, $5 00. 
Three complete and extended Indexes render the work especially adapted for immediate consul- 
tation. One, of Diseases and their Remedies, presents under the head of each disease the 
remedial agents which have been usefully exhibited in it, with reference to the formulae containing 
them — while another of Pharmaceutical and Botanical Names, and a very thorough General 
Index afford the means of obtaining at once any information desired. The Formulary itself is 
arranged alphabetically, under the heads of the leading constituents of the prescriptions. 

We know of none in our language, or any other, so comprehensive in its details. — London Lancet. 
One of the most complete works of the kind in any language. — Edinburgh Med. Journal. 
We are not cognizant of the existence of a parallel work. — London Med. Gazette. 



Henry C. Lea's Publications — {Mat. Med. and Therapeutics). 13 

pEREIRA {JONATHAN), M.D., F.R.S. and L.S. 

MATERIA MEDICA AND THERAPEUTICS; being an Abridg- 

ment of the late Dr. Pereira's Elements of Materia Medica, arranged in conformity with 
the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemists and 
Druggists, Medical and Pharmaceutical Students, &c. By F. J. Farre, M.D., Senior 
Physician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia; 
assisted by Robert Bentley, M.R.C.S., Professor of Materia Medica and Botany to the 
Pharmaceutical Society of Great Britain; and by Robert Warington, F.R.S. , Chemical 
Operator to the Society of Apothecaries. With numerous additions and references to the 
United States Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the 
University of Pennsylvania. In one large and handsome octavo volume of 1040 closely 
printed pages, with 236 illustrations, extra cloth, $7 00; leather, raised bands, $8 00. 



The task of the American editor has evidently been 
no sinecure, for not only has he given to us all that 
is contained in the abridgment useful for our pur- 
poses, but by a careful and judicious embodiment of 
over a hundred new remedies has increased the size 
of the former work fully one-third, besides adding 
many new illustrations, some of which are original. 
We unhesitatingly say that by so doing he has pro- 
portionately increased the value, not only of the con- 
densed edition, but has extended the applicability of 
the great original, and has placed his medical coun- 
trymen under lasting obligations to him. The Ame- 
rican physician now has all that is needed in the 
shape of a complete treatise on materia medica, and 
the medical student has a text-book which, for prac- 
tical utility and intrinsic worth, stands unparalleled. 
Although of considerable size, it is none too large for 
the purposes for which it has been intended, and every 
medical man should, in justice to himself, spare a 
place for it upon his book-shelf, resting assured that 
the more he consults it the better he will be satisfied 
of its excellence.— -AT. Y. Med. Record, Nov. 15f 1S66. 

It will fill a place which no other work can occupy 
in the library of the physician, student, and apothe- 
cary. — Boston Med. and Surg. Journal, Nov. 8, 1866. 

Of the many works on Materia Medica which have 
appeared since the issuing of the British Pharmaco- 



poeia, none will be more acceptable to the student 
and practitioner than the present. Pereira's Materia 
Medica had long ago asserted for itself the position of 
being the most complete work on the subject in the 
English language. But its very completeness stood 
in the way of its success. Except in the way of refer- 
ence, or to those who made a special study of Materia 
Medica, Dr. Pereira's work was too full, and its pe- 
rusal required an amount of time which few had at 
their disposal. Dr. Farre has very j udiciously availed 
himself of the opportunity of the publication of the 
new Pharmacopoeia, by bringing out an abridged edi- 
tion of the great work. This edition of Pereira is by 
no means a mere abridged re-issue, but contains ma- 
ny improvements, both in the descriptive and thera- 
peutical departments. We can recommend it as a 
very excellent and reliable text-book. — Edinburgh 
Med. Journal, February, 1S66. 

The reader cannot fail to be impressed, at a glance, 
with the exceeding value of this work as a compeud 
of nearly all useful knowledge on the materia medica. 
We are greatly indebted to Professor Wood for his 
adaptation of it to our meridian. Without his emen- 
dations and additions it would lose much of its value 
to the American student. With them it is an Ameri- 
can book. — Pacific Medical and Surgical Journal, 
December, 1S66. 



PLLIS {BENJAMIN), M.D. 

THE MEDICAL FORMULARY: being a Collection of Prescriptions 

derived from the writings and practice of mnny of the most eminent physicians of America 
and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. The 
whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- 
tion, carefully revised and much improved by Albert H. Smith, M.D. In one volume 8vo. 
of 376 pages, extra cloth, $3 00. {Lately Published.) 
This work has remained for some time out of print, owing to the anxious care with which the 
Editor has sought to render the present edition worthy a continuance of the very remarkable 
favor which has carried the volume to the unusual honor of a Twelfth Edition. He has sedu- 
lously endeavored to introduce in it all new preparations and combinations deserving of confidence, 
besides adding two new classes, Antemetics and Disinfectants, with brief references to the inhalation 
of atomized fluids, the nasal douche of Thudichum, suggestions upon the method of hypodermic 
injection, the administration of anaesthetics, <fcc. <fec. To accommodate these numerous additions, 
he has omitted much which the advance of science has rendered obsolete or of minor importance, 
notwithstanding which the volume has been increased by more than thirty pages. A new feature 
will be found in a copious Index of Diseases and their remedies, which cannot but increase the 
value of the work as a suggestive book of reference for the working practitioner. Every precaution 
has been taken to secure the typographical accuracy so necessary in a work of this nature, and it 
is hoped that the new edition will fully maintain the position which " Ellis' Formulary' : has 
long occupied. 



a 



ARSON {JOSEPH), M.D., 

Professor of Materia Medica and Pharmacy in the University of Pennsylvania, &c. 

SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA 

MEDICA AND PHARMACY, delivered in the University of Pennsylvania. With three 
Lectures on the Modus Operandi of Medicines. Fourth and revised edition, extra cloth, 
$3 00. 



DUNGLISON'S NEW REMEDIES, WITH FORMULAE 
FOR THEIR PREPARATION AND ADMINISTRA- 
TION. Seventh edition, with extensive additions. 
One vol. Svo , pp. 770; extra cloth. $1 00. 

ROTLES MATERIA MEDICA AND THERAPEU- 
TICS. Edited by Joseph Carson, M. D. With 
ninety-eight illustrations. 1 vol. Svo., pp. 700, ex- 
tra cloth. $3 00. 

CHRISTISON'S DISPENSATORY. With copious ad- 
ditions, and 213 large wood-engravings. By R 



Eglesfeld Griffith, M.D. One vol. 8vo., pp. 1000 ; 
extra cloth. $4 00. 

CARPENTER'S PRIZE ESSAY ON THE USE OF 
Alcoholic Liquors in Health and Disease. New 
edition, with a Preface by D. F. Condte, M.D., and 
explanations of scientific words. In one neat 12mo. 
volume, pp. 17S, extra cloth. 60 cents. 

De JONGH ON THE THREE KINDS OF COD-LIVER 
Oil, with their Chemical and Therapeutic Pro- 
perties 1 vol. 12mo., cloth. 75 cents. 



14 



Henry C. Lea 7 s Publications — (Pathology). 



fIROSS {SAMUEL D.), M. D., 

^J> Professor of Surgery in the Jefferson Medical College of Philadelphia. 

ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, 

thoroughly revised and greatly improved. In one large and very handsome octavo vol jme 
of nearly 800 pages, with about three hundred and fifty beautiful illustrations, of which a 
large number are from original drawings ; extra cloth. $4 00. 
The very beautiful execution of this valuable work, and the exceedingly low price at which it 
is offered, should command for it a place in the library of every practitioner. 

Charles- 



To the student of medicine we would say that we 
know of no work which we can more heartily com- 
mend than Gross's Pathological Anatomy. — Southern 
Med. and Surg. Journal. 

The volume commends itself to the medical student ; 

will repay a careful perusal, and should be upon 



the hook-shel f of every American physician. 
ton Med. Journal. 

It contains much new matter, and brings down our 
knowledge of pathology to the latest period. — London 
Lancet. 



TONES (G. HAND FIELD), F.R.S., and SIEV EKING [ED. H), M.D., 

*-J Assistant Physicians and Lecturers in St. Mary's Hospital. 

A MANUAL OF PATHOLOGICAL ANATOMY. First American 

edition, revised. With three hundred and ninety- seven handsome wood engravings. In 
one large and beautifully printed octavo volume of nearly 750 pages, extra cloth, $3 50. 



Our limited space alone restrains us from noticing 
more at length the various subjects treated of in 
this interesting work ; presenting, as it does, an excel- 
lent summary of the existing state of knowledge in 
relation to pathological anatomy, we cannot too 
strongly urge upon the student the necessity of a tho- 
rough acquaintance with its contents. — Medical Ex- 
aminer. 

We have long had need of a hand-book of patholo- 
gical anatomy which should thoroughly reflect the 
present state of that science. In the treatise before 
as this desideratum is supplied. Within the limits of 
a moderate octavo, we have the outlines of this great 
department of medical science accurately defined, 



and the most recent investigations presented in suffi- 
cient detail for the student of pathology. We cannot 
at this time undertake a formal analysis of this trea- 
tise, as it would involve a separate and lengthy 
consideration of nearly every subject discussed ; nor 
would such analysis be advantageous to the medical 
reader. The work is of such a character that every 
physician ought to obtain it, both for reference and 
study. — N. Y. Journal of Medicine. 

Its importance to the physician cannot be too highly 
estimifced, and we would recommend our readers to 
add it to their library as soon as they conveniently 
can. — Montreal Med. Chronicle. 



GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. 

Translated, with Notes and Additions, by Joseph 
Leidy, M. D. In one volume, very large imperial 
quarto, with 320 copper-plate figures, plain and 
colored, extra cloth. $i 00. 



SIMON'S GENERAL PATHOLOGY, as conducive to 
the Establishment of Rational Principles for the 
Prevention and Cure of Disease. In one octavo 
volume of 212 pages, extra cloth. $1 25. 



T^ILLIAMS (CHARLES J. B.), 31. V., 

' ' Professor of Clinical Medicine in University College, London. 

PRINCIPLES OF MEDICINE. An Elementary Yiew of the Causes, 

Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, 
or the preservation of health. A new American, from the third and revised London edition. 
In one octavo volume of about 500 pages, extra cloth. $3 50. 
No work has ever achieved or maintained a more 

deserved reputation. — Virginia Med. and Surg. 

Journal. 
There is no work in medical literature which can 

fill the place of this one. It is the Primer of the 

young practitioner, the Koran of the scientific one. — 

Stethoscope. 



A text-book to which no other in our language is 
comparable. — Charleston Med. Journal. 



The absolute necessity of such a work must be 
evident to all who pretend to more than mere 
empiricism. We must conclude by again express- 
ing our high sense of the immense benefit which 
Dr. Williams has conferred on medicine by the pub- 
lication of this work. We are certain that in the 
present state of our knowledge his Principles of Medi- 
cine could not possibly be surpassed. — London Jour, 
of Medicine. 



HARRISON'S ESSAY TOWARDS A CORRECT 
THEORY OF THE NERVOUS SYSTEM. In one 
octavo volume of 2.92 pp. $1 50. 

SOLLY ON THE HUMAN BRAIN : its Structure, Phy- 
siology, and Diseases. From the Second and much 
enlarged London edition. In one octavo volume of 
.500 pages. with 120 wood-cuts: extra cloth. $2 50. 

LA ROCHE ON YELLOW FEVER, considered in its 
Historical, Pathological, Etiological, and Therapeu- 
tical Relations. In two large and handsome octavo 
volumes, of nearly 1500 pages, extra cloth, $7 00. 

LA ROCHE ON PNEUMONIA ; its Supposed Connec- 
tion, Pathological, and Etiological, with Autumnal 



Fevers, including an Inquiry into the Existence aDd 
Morbid Agency of Malaria. In one handsome oc- 
tavo volume, extra cloth, of 500 pages. Price $3 on. 

BUCKLER ON FIBRO-BRONCHITIS AND RHEU- 
MATIC PNEUMONIA. In one octavo vol., extra 
cloth, pp. 150. $1 25. 

FISKE FUND PRIZE ESSAYS.— LEE ON THE EF- 
FECTS OF CLIMATE ON TUBERCULOUS DIS- 
EASE. AND WARREN ON THE INFLUENCE OF 
PREGNANCY ON THE DEVELOPMENT OF TU- 
BERCLES. Together in one neat octavo volume 
extra cloth, $1 00. 



T>ARCLAY [A. W.), M. D. 

A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the 

Signs and Symptoms of Disease. Third American from the second and revised London 
edition. In one neat octavo volume of 451 pages, extra cloth. $3 50. 

A work of immense practical utility. — London I The book should be in the hands of every practical 
Med. Times and Gazette. man. — Dublin Med. Press. 



Henry C. Lea's Publications — {Practice of Medicine). 



15 



JPLINT (AUSTIN), M.D., 

J- Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. T. 

A TREATISE ON THE PRINCIPLES AND PRACTICE OF 

MEDICINE ; designed for the use of Students and Practitioners of Medicine. Third 
edition, revised and enlarged. In one large and closely printed octavo volume of 1002 
pages ; handsome extra cloth, $6 00 ; or strongly hound in leather, with raised bands, $7 00. 
(Just Issued.) 

From the Preface to the Third Edition. 
Since the publication, in December, 1866, of the second edition of this treatise, much time has 
been devoted to its revision. Recognizing in the favor with which it has been received a pro- 
portionate obligation to strive constantly to increase its worthiness, the author has introduced in 
the present edition additions, derived from his clinical studies, and from the latest contributions 
in medical literature, which, it is believed, will enhance considerably the practical utility of the 
work. A slight modification in the typographical arrangement has accommodated these additions 
without materially increasing the bulk of the volume. 
New York, October, 1868. 

At the very low price affixed, the profession will find this to he one of the cheapest volumes 
within their reach. 



This work, which stands pre-eminently as the ad- 
vance standard of medical science up to the present 
time in the practice of medicine, has for its author 
one who is well and widely known as one of the 
leading practitioners of this continent. In fact, it is 
seldom that any work is ever issued from the press 
more deserving of universal recommendation. — Do- 
minion Med. Journal, May, 1869. 

The third edition of this most excellent book scarce- 
ly needs any commendation from us. The volume, 
as it stands now, is really a marvel : first of all, it is 
excellently printed and bound — and we encounter 
that luxury of America, the ready-cut pages, which 
the Yankees are 'cute enough to insist upon — nor are 
these by any means trifles ; but the contents of the 
book are astonishing. Not only is it wonderful that 
any one man can have grasped in his mind the whole 
scope of medicine with that vigor which Dr. Flint 
shows, but the condensed yet clear way in which 
this is done is a perfect literary triumph. Dr. Flint 
is pre-eminently one of the strong men, whose right 
to do this kind of thing is well admitted ; and we say 
no more than the truth when we aftirm that he is 
very nearly the only living man tliat could do it with 
such results as the volume before us. — The London 
Practitioner, March, 1869. 

This is in some respects the best text-book of medi- 
cine in our language, and it is highly appreciated on 
the other side of the Atlantic, inasmuch as the first 
edition was exhausted in a few months. The second 
edition was little more than a reprint, but the pi'esent 
has, as the author says, been thoroughly revised. 
Much valuable matter has been added, and by mak- 
ing the type smaller, the bulk of the volume is not 
much increased. The weak point in many American 
works is pathology, but Dr. Flint has taken peculiar 
pains on this poiut, greatly to the value of the book. 
— London Med. Times and Gazette, Feb. 6, IS69. 

Published in 1866, this valuable book of Dr. Flint's 
has in two years exhausted two editions, and now 
we gladly announce a third. We say we gladly an- 
nounce it, because we are proud of it as a national 
representative work of not only American, but of 



cosmopolitan medicine. In it the practice of medicine 
is young and philosophical, based on reason and com- 
mon sense, and as such, we hope it will be at the 
right hand of every practitioner of this vast continent. 
— California Medical Gazette, March, 1869. 

Considering the large number of valuable works in 
the practice of medicine, already before the profes- 
sion, the marked favor with which this has been re- 
ceived, necessitating a third edition in the short space 
of two years, indicates unmistakably that it is a work 
of more than ordinary excellence, and must be accept- 
ed as evidence that it has largely fulfilled the object 
for which the author intended it. A marked feature 
in the work, and one which particularly adapts it for 
the use of students as a text-book, and certainly ren- 
ders it none the less valuable to the busy practitioner 
as a work of reference, is brevity and simplicity. 
The present edition has been thoroughly revised, and 
much new matter incorporated, derived, as the author 
informs us, both from his own clinical studies, and 
from the latest contributions to medical literature, 
thus bringing it fully up with the most recent ad- 
vances of the science, and greatly enhancing its prac 
tical utility; while, by a slight modification of its 
typographical arrangement, the additions have been 
accommodated without materially increasing its 
bulk.— St Louis Mtd. Archives, Feb. 1869. 

If there be among our readers any who are not fa- 
miliar with the treatise before us, we shall do them 
a service in persuading them to repair their omission 
forthwith. Combiniug to a rare degree the highest 
scientific attainments with the most practical com- 
mon sense, and the closest habits of observation, the 
author has given us a volume which not only sets 
forth the results of the latest investigations of other 
laborers, but contains more original views than any 
other single work upon this well-worn theme within 
our knowledge.— N. Y. Med. Gazette, Feb. 27, 1869. 

Practical medicine was at sea when this book ap- 
peared above the horizon as a safe and capacious har- 
bor. It came opportunely and was greeted with 
pleasurable emotions throughout the land. — Nash- 
ville Med. and Surg. Journal, May, 1S69. 



JTiDNGLISON, FORBES, TWEEDIE, AND CONOLLY. 

THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising 

Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, 
Diseases of Women and Children, Medical Jurisprudence, Ac. &c. In four large super-royal 
octavo volumes, of 3254 double-columned pages, strongly and handsomely bound in leather, 
$15; extra cloth, $11. 

*%* This work contains no less than four hundred and eighteen distinct treatises, contributed 
by sixty-eight distinguished physicians. 



The most complete work on practical medicine 
extant, or at least in our language. — Buffalo Medical 
and Surgical Journal. 

For reference, it is above all price to every practi- 
tioner.— Western Lancet. 

One of the most valuable medical publications of 



the day. As a work of reference it is invaluable. — 
Western Journal of Medicine and Surgery. 

It has been to us, both as learner and teacher, a 
work for ready and frequent reference, one in which 
modern English medicine is exhibited in the most ad- 
vantageous light. — Medical Examiner. 



BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With Additions by D. F. Condie, 
M. D. 1 vol. 8vo., pp. 600, cloth. $2 50. 



HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. From the third and enlarged English edi- 
tion. In one handsome octavo volume of about 
500 pages, extra cloth. $3 50. 



16 



Henry C. Lea's Publications — {Practice of Medicine). 



IJARTSHORNE (HENRY), M.D., 

J. J. Professor of Hygiene in the University of Pennsylvania. 

ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- 
CINE. A handy-book for Students and Practitioners. Second edition, revised and im- 
proved. In one handsome royal 12mo. volume of 450 pages, clearly printed on small type, 
cloth, $2 38 ; half bound, $2 63. 
The very cordial reception with which this work has met shows that the author has fully suc- 
ceeded in his attempt to condense within a convenient compass the essential points of scientific 
and practical medicine, so as to meet the wants not only of the student, but also of the practi- 
tioner who desires to acquaint himself with the results of recent advances in medical science. 

safe and accomplished companion. We speak thus 



As a strikingly terse, full, and comprehensive em- 
bodiment in a condensed form of the essentials in 
medical science and art, we hazard nothing in saying 
that it is incomparably in advance of any work of the 
kind of the past, and will stand long in the future 
without a rival. A mere glance will, we think, im- 
pi-ess others with the correctness of our estimate. Nor 
do we believe there will be found many who, after 
the most cursory examination, will fail to possess it. 
How one could be able to crowd so much that is valu- 
able, especially to the student and young practitioner, 
within the limits of so small a book, and yet embrace 
and present all that is important in a well-arranged, 
clear form, convenient, satisfactory for reference, with 
so full a table of contents, and extended general index, 
with nearly three hundred formulas and recipes, is a 
marvel.— Western Journal of Medicine, Aug. 1867. 

The little book before us has this quality, and we 
can. therefore say that all students will find it an in- 
valuable guide in their pursuit of clinical medicine. 
Dr. Hartshorne speaks of it as "an unambitious effort 
to make useful the experience of twenty years of pri- 
vate and hospital medical practice, with its attendant 
study and reflection." That the effort will prove suc- 
cessful we have no doubt, and in his study, and at 
the bedside, the student will find Dr. Hartshorne a 



highly of the volume, because it approaches mon 
nearly than any "similar manual lately before us the 
standard at which all such books should aim — of 
teaching much, and suggesting more. To the student 
we can heartily recommend the work of our transat- 
lantic colleague, and the busy practitioner, we are 
sure, will find in it the means of solving many a 
doubt, and will rise from the perusal of its pages, 
having gained clearer views to guide him in his daily 
struggle with disease. — Dub. Med. Press, Oct. 2, 1S67. 
This work of Dr. Hartshorne must not be confound- 
ed with the medical manuals so generally to be found 
in the hands of students, serving them at best but as 
blind guides, better adapted to lead them astray than 
to any useful and reliable knowledge. The work be- 
fore us presents a careful synopsis of the essential 
elements of the theory of diseased action, its causes, 
phenomena, and results, and of the art of healing, as 
recognized by the most authoritative of our profes- 
sional writers and teachei-s. A very careful and can- 
did examination of the volume has convinced us that 
it will be generally recognized as one of the best man- 
uals for the use of the student that has yet appeared. 
— American Journal Med. Sciences, Oct. 1867. 



TUATSON (THOMAS), M. D., £c. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF 

PHYSIC. Delivered at King's College, London. A new American, from the last revised 
and enlarged English edition, with Additions, by D. Francis Condie, M. D., author of 
"A Practical Treatise on the Diseases of Children," &c. With one hundred and eighty- 
five illustrations on wood. In one very large and handsome volume, imperial octavo, of 
over 1200 closely printed pages in small type ; extra cloth, $6 50 ; strongly bound in 
leather, with raised bands, $7 50. 
Believing this to be a work which should lie on the table of every physician, and be in the hands 
of every student, every effort has been made to condense the vast amount of matter which it con- 
tains within a convenient compass, and at a very reasonable price, to place it within reach of all. 
In its present enlarged form, the work contains the matter of at least three ordinary octavos, 
rendering it one of the cheapest works now offered to the American profession, while its mechani- 
cal execution makes it an exceedingly attractive volume. 



DICKSON'S ELEMENTS OF MEDICINE; a Compen- 
dious View of Pathology and Therapeutics, or the 
History and Treatment of Diseases. Second edi- 
tion, revised. 1 vol. 8vo. of 750 pages, extra cloth. 
$4 00. 

WHAT TO OBSERVE AT THE BEDSIDE AND AFTER 
Death in Medical Cases. Published under the 
authority of the London Society for Medical Obser- 



1 vol. 



vation. From the second London edition, 
royal 12mo., extra cloth. $1 00. 
LAYCOCK'S LECTURES ON THE PRINCIPLES 
and Methods of Medical Observation and Re- 
search. For the use of advanced students and 
junior practitioners. In one very neat royal 12m o. 
volume, extra cloth. $1 00. 



PULLER (HENRY WILLIAM), M. D., 

-*- Physician to St. George's Hospital, London. 

ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their 

Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised 

English edition. In one handsome octavo volume of about 500 pages, extra cloth, $3 50. 

Dr. Fuller's work on diseases of the chest was so 

favorably received, that to many who did not know 

the extent of his engagements, it was a matter of won 



der that it should be allowed to remain three years 
out of print. Determined, however, to improve it, 
Dr. Fuller would not consent to a mere reprint, and 



accordingly we have what might be with perfect jus- 
tice styled an entirely new work from his pen, the 
portion of the work treating of the heart and great 
vessels being excluded. Nevertheless, this volume is 
of almost equal size with the first. — London Medical 
Times and Gazette, July 20, 1867. 



J^RINTON (WILLIAM), M.D., F.R.S. 

LECTURES ON THE DISEASES OF THE STOMACH; with an 

Introduction on its Anatomy and Physiology. From the second and enlarged London edi- 
tion. With illustrations on wood. In one handsome octavo volume of about 300 pages, 
$3 25. 



extra cloth. 

Nowhere can be found a more full, accurate, plain, 
and instructive history of these diseases, or more ra- 
tional views respecting their pathology and therapeu- 
tics. — Am. Journ. of the Med. Sciences, April, 1865. 



The most complete work in our language upon the 
diagnosis and treatment of these puzzling and impor- 
tant diseases. — Boston Med. and Surg. Journal, Nov. 
1865. 



Henry C. Lea's Publications — {Practice of Medicine). 



n 



JPLINT (A USTIN), M. D., 

J- Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. T. 

A PRACTICAL TREATISE OX THE DIAGNOSIS, PATHOLOGY, 

AND TREATMENT OF DISEASES OP THE HEART. Second revised and enlarged 

edition. In one octavo volume of 550 pages, with a plate, extra cloth, $4. (Just Issued.) 

The author has sedulously improved the opportunity afforded him of revising this work. Portions 

of it have been rewritten, and the whole brought up to a level with the most advanced condition of 

science. It must therefore continue to maintain its position as the standard treatise on the subject. 



Dr. Flint chose a difficult subject for his researches, 
and has shown remarkable powers of observation, 
and reflection, as well as great industry, in his treat- 
ment of it. His book must be considered the fullest 
and clearest practical treatise on those subjects, and 
should be in the hands of all practitioners and stu- 
dents. It is a credit to American medical literature. 
— Amer. Journ. of the Med. Sciences, July, 1S60. 

We question the fact of any recent American author 
in our profession being more extensively known, or 
more deservedly esteemed in this country than Dr. 
Flint. We willingly acknowledge his success, more 
particularly in the volume on diseases of the heart, 
in making an extended personal clinical study avail- 



able for purposes of illustration, in connection with 
cases which have been reported by other trustworthy 
observers. — Brit, and For. Med.-Chirurg. Review. 

In regard to the merits of the work, we have no 
hesitation in pronouncing it full, accurate, and judi- 
cious. Considering the present state of science, such 
a work was much needed. It shonld be in the hands 
of every practitioner. — Chicago Med. Journ. 

With more than pleasure do we hail the advent of 
this work, for it fills a wide gap on the list of text- 
books for our schools, and is, for the practitioner, the 
most valuable practical work of its kind.— N. 0. Med. 
News. 



£Y THE SAME AUTHOR. (Just Issued.) 

A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and revised edition. In one handsome octuvo volume 
of 595 pages, extra cloth, $4 50. 

great practical value. Dr. Flint's style is clear. and 
elegant, and the tone of freshness and originality 
which pervades his whole work lend an additional 
force to its thoroughly practical character, which 
cannot fail to obtain for it a place as a standard work 
on diseases of the respiratory system. — London 
Lancet, Jan. 19, 1S67. 

This is an admirable book. Excellent in detail and 
execution, nothing better could be desired by the 
practitioner. Dr. Flint enriches his subject with 
much solid and not a little original observation. — 
Ranking 1 s Abstract, Jan. 1867. 



Premising this observation of the necessity of each 
student and practitioner making himself acquainted 
with auscultation and percussion, we may state our 
honest opinion that Dr. Flint's treatise is one of the 
most trustworthy guides which he can consult. The 
style is clear and distinct, and is also concise, being 
free from that tendency to over-refinement and unne- 
cessary minuteness which characterizes many works 
on the same subject. — Dublin Medical Press, Feb. 6, 
1867. 



The chapter on Phthisis is replete with interest; 
and his remarks on the diagnosis, especially in the 
early stages, are remarkable for their acumen and 



p A VY (F. W.), M. D., F. R. S. , 

-*- Senior Asst. Physician to and Lecturer on Physiology, at Guy's Hospital, &c. 

A TREATISE ON THE FUNCTION OF DIGESTION; its Disor- 

ders and their Treatment. From the second London edition. In one handsome volume, 
small octavo, extra cloth, $2 00. (Lately Published.) 
The work before us is oue which deserves ft wide treatise, and sufficiently exhaustive for all practical 



circulation. We know of no better guide to the study 
of digestion and its disorders. — St. Louis Med. and 
Surg. Journal, July 10, 1869. 
A thoroughly good book, being a careful systematic 



purposes.— Leavenworth Med. Herald, July, 1869. 

A very valuable work on the subject of which it 
treats. Small, yet it is full of valuable information. 
—Cincinnati Med. Repertory, June, 1869. 



ftHAMBERS [T. K.), M.D., 

^ Consulting Physician to St. Mary's Hospital, London, &c. 

THE INDIGESTIONS ; or, Diseases of the Digestive Organs Functionally 

Treated. Third and revised Edition. In one handsome octavo volume of 333 pages, extra 
cloth. $3 00. (Just Issued.) 

Author's Preface. 

Since publishing my first edition, I have inserted upwards of ten dozen cases, and have rear- 
ranged, indeed in part rewritten, the commentary upon them. A third edition is not yet required 
in England, so I send the MS. for publication to America. I have faith in the kindly feeling 
with which it will be received there. 

London, December, 1869. 

We look upon this chapter as a most valuable guide 
to physicians, and warniug to patients concerning 
transgressions against the established physiological 
conduct of life. The advice as to medical treatment 
proper, is also most serviceable. It should be read 
by every medical man in the country, and he should 
read his lessons to his patients from out its pages. We 



only regret that we have no room for a more thorough 
analysis of its contents.— N. Y. Medical Journal, 
March, 1668. 

The work should be in the hands of every practis- 
ing physician.— Boston Med. and Surg. Journal, 
Nov. 21, 1S67. 



SMITH ON CONSUMPTION; ITS EARLY AND RE- 
MEDIABLE STAGES. In one neat octavo volume 
of 254 pages, extra cloth. $2 25. 

SALTER ON ASTHMA; its Pathology, Causes, Con- 
sequences, and Treatment. In one volume octavo, 
extra cloth. $2 50. 

TODD'S CLINICAL LECTURES ON CERTAIN ACUTE 



Diseases. In one neat octavo volume, of 320 pages, 
extra cloth. *2 50. 
WALSHE'S PRACTICAL TREATISE ON THE DIS- 
EASES OF THE HEART AND GREAT VESSELS. 
Third American, from the third revised and much 
enlarged London edition. In oue handsome octavo 
volume of 420 pages, extra cloth. $3 00. 



18 



Henry C. Lea's Publications — {Practice of Medicine). 



ROBERTS { WILLIAM) 

-*-* / Lecturer on Medicine in t) 



M.D., 

Manchester School of Medicine, &c. 

PRACTICAL TREATISE ON URINARY AND RENAL DIS- 

EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- 
ond Edition, Revised. In one very handsome octavo volume. {Preparing.) 



ft ASH AM (W.R.), M.D., 

■*-* Senior Physician to the Westminster Hospital, &c. 

RENAL DISEASES: a Clinical Guide to their Diagnosis and Treat- 

ment. With illustrations. In one neat royal 12mo. volume of 304 pages. $2 00. {Just 
Issued. ) 



The chapters on diagnosis and treatment are very 
good, and the student and young practitioner will 
find thern full of valuable practical hints. The third 
part, on the urine, is excellent, and we cordially 
recommend its perusal. The author has arranged 
his matter in a somewhat novel, and, we think, use- 
ful form. Here everything can be easily found, and, 
what is more important, easily read, for all the dry 
details of larger books here acquire a new interest 
from the author's arrangement. This part of the 
book is full of good work. — Brit, and For. Medico- 
Chirurgical Review, July, 1870. 

The easy descriptions and compact modes of state- 



ment render the book pleasing and convenient. — Am. 
Journ. Med. Sciences, July, 1870. 

A book that we believe will be found a valuable 
assistant to the practitioner and guide to the student. 
— Baltimore Med. Journal, July, 1870. 

The treatise of Dr. Basham differs from the rest in 
its special adaptation to clinical study, and its con- 
densed and almost aphorismal style, which makes it 
easily read and easily understood. Besides, the 
author expresses some new views, which are well 
worthy of consideration. The volume is a valuable 
addition to this department of knowledge. — Pacific 
Med. and Surg. Journal, July, 1870. 



MOKLAND ON EETENTION IN THE BLOOD OF THE ELEMENTS OF THE UKINARY SECRETION. 
1 vol. Svo., extra cloth. 75 cents. 



TONES {C. HANDFIELD), M. D., 

*J Physician to St. Mary's Hospital, &e. 

CLINICAL OBSERVATIONS 

DISORDERS. Second American Edition, 
extra cloth, $3 25. 

Taken as a whole, the work before us furnishes a 
6hort but reliable account of the pathology and treat- 
ment of a class of very common but certainly highly 
obscure disorders. The advanced student will find it 
a rich mine of valuable facts, while the medical prac- 
titioner will derive from it many a suggestive hint to 
aid him in the diagnosis of "nervous cases," and in 
determining the true indications for their ameliora- 
tion or cure.— Amer. Journ. Med. Set, Jan. 1867. 



ON FUNCTIONAL NERVOUS 

In one handsome octavo volume of 348 pages, 

We must cordially recommend it to the profession 
of this country as supplying, in a great measure, a 
deficiency which exists in the medical literature of 
the English language. — New York Med. Journ., April, 
1S67. 

The volume is a most admirable one — full of hints 
and practical suggestions. — Canada Med. Journal, 
April, 1S67. 



E- 



'SSA YS ON NER VO US DISEASES {Now Ready.) 

ON DISEASES OF THE SPINAL COLUMN AND OF THE 

NERVES. By C. B. Radcliff, M. D., John Netten Radcliff, J. Warburton Beg- 
bie, M. D., Francis E. Ainstie, M. D., and J. Russell Reynolds, M. D. 1 vol. 8vo., 
extra cloth, $1 50. 
This volume, which has been passing through the Library Department of the "Medical 
News 1 ' for 1870, consists of a series of essays from " Reynolds' System of Medicine" by gentle- 
men who have paid especial attention to the several affections of the nervous system. 



s 



LADE {D. D.), M.D. 

DIPHTHERIA; its Nature and Treatment, with an account of the His- 
tory of its Prevalence in various Countries. Second and revised edition. In one neat 
royal 12mo. volume, extra cloth. $1 25. 



TTUDSON {A.), M. D., M. R. I. A., 

•*--*• Physician to the Meath Hospital. 

LECTURES ON THE STUDY OF FEVER. 

Cloth, $2 50. 



In one vol. 8vo., extra 



As an admirable summary of the present state of 
our knowledge concerning fever, the work will be as 
welcome to the medical man in active practice as to 
the student. To the hard-worked practitioner who 
wishes to refresh his notions concerning fever, the 

book will prove most valuable We heartily 

commend his excellent volume to students and the 
profession at large. — London Lancet, June 22, 1S67. 

The truly philosophical lectures of Dr. Hudson add 



much to our previous knowledge, all of which they, 
moreove'r, analyze and condense. This well-conceived 
task has been admirably executed in the leciures, il- 
lustrative cases and quotations being arranged in an 
appendix to each. We regret that space forbids our 
quotation from the lectures on treatment, which are, 
in regard to research and judgment, most masterly, 
and evidently the result of extended and mature ex- 
perience. — British Medical Journal, Feb. 22, 186S. 



TONS {ROBERT D.), K.G.G. 
A TREATISE ON FEVER: 



or, Selections from a Course of Lectures 



on Fever. Being part of a Course of Theory and Praotice of Medicine, 
volume, of 362 pages, extra cloth. $2 25. 



In one neat octavo 



Henry C. Lea's Publications — ( Venereal Diseases, etc.). 



19 






TJUMSTEAD {FREEMAN J.), M.D., 

X> Profestor of Venereal Diseases at the Col. of Phys. and Surg., New York, &c. 

THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- 
EASES. Including the results of recent investigations upon the subject. Third edition, 
revised and enlarged, with illustrations. In one large and handsome octavo volume of 
over 700 pages, extra cloth, $5 00. {Now Ready.) 
Well known as one of the best authorities of the every other treatise on Venereal.— San Francisco 

Med. Press, Oct. 1864. 

A perfect compilation of all that is worth knowing 
on venereal diseases in general. It fills up a gap 
which has long been felt in English medical literature. 
— Brit, and Foreign Med.-Chirurg. Review, Jan., : 65. 



present day on the subject.— Br it ish and For. Med.- 
Chirurg. Review, April, 1S66. 

A regular store-house of special information.— 
London Lancet, Feb. 24, 1866. 

A remarkably clear and full systematic treatise on 
the whole subject— Lond. Med. Times and Gazette. 

The best, completest, fullest monograph on this 
subject in our language.— British American Journal. 

Indispensable in a medical library. — Pacific Med. 
and Surg. Journal. 

We have no doubt that it will supersede in America 



(7ULLERIER [A.), and 

^ Surgeon to the Hopital du Midi. 



We have not met with any which so highly merits 
our approval and praise as the second edition of Dr. 
Bumstead'swork. — Glasgow Med. Journal, Oct. 1864. 

We know of no treatise in any language which is 
its equal in point of completeness and practical sim- 
plicity. — Boston Medical and Surgical Journal, 
Jan. 30, 1S64. 



J)UMSTEAD {FREEMAN J. 

-*-* Professor of Venereal Diseases in th 



the College of 



AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 

Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, 
with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
life; strongly bound in extra cloth, $17 00 ; also, in five parts, stout wrappers for mailing, at 
$3 per part. {Lately Published.) 

Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
lars a Part, thus placing it within the reach of all who are interested in this department of prac- 
tice. Gentlemen desiring early impressions of the plates would do weH to order it without delay. 

A specimen of the plates and text sent free by mail, on receipt of 25 cents. 

We wish for once that our province was not restrict- 
ed to methods of treatment, that we might say some- 
thing of the exquisite colored plates in this volume. 
— London Practitioner, May, 1S69. 

As a whole, it teaches all that can be taught by 
means of plates and print. — London Lancet, March 
13, 1869. 

Superior to anything of the kind ever before issued 
on this continent. — Canada. Med. Journal, March, 69. 

The practitioner who desires to understand this 
branch of medicine thoroughly should obtain this, 
the most complete and best work ever published. — 
Dominion Med. Journal, May, 1869. 

This is a work of master hands on both sides. M. 
Cullerier is scarcely second to, we think we may truly 
say is a pepr of the illustrious and veuerable Ricord, 
■while in this country we do not hesitate to say that 
Dr. Bumstead, as an authority, is without a rival 
Assuring our readers that these illustrations tell the 
whole history of venereal disease, from its inception 
to its end, we do not know a single medical work, 
which for its Kind is more necessary for them to have. 
— California Med. Gazette, March, 1S69. 

The most splendidly illustrated work in the lan- 
guage, and in our opinion far more useful than the 
French original.— Am. Journ. Med. Sciences, Jan. '69. 



The fifth and concluding number of this magnificent 
work has reached us, and we have no hesitation in 
saying that its illustrations surpass those of previous 
numbers.— Boston Med. and Surg. Journal, Jan. 14, 
1S69. 

Other writers besides M. Cullerier have given us a 
good account of the diseases of which he treats, but 
no one has furnished us with such a complete series 
of illustrations of the venereal diseases. There i*, 
however, an additional interest and value possessed 
by the volume before us ; for it is an American reprint 
and translation of M. Cullerier's work, with inci- 
dental remarks by one of the most eminent American 
syphilographers, Mr. Bumstead. The letter-press is 
chiefly M. Cullerier's, but every here and there a few 
lines or sentences are introduced by Mr. Bumstead ; 
and, as M. Cullerier is a uuicist, while Mr. Bumstead 
is a dualist, this method of treating the subject adds 
very much to its interest. By this means a liveliness 
is imparted to the volume which many other treatises 
sorely lack. It is like reading the report of a conver- 
sation or debate ; for Mr. Bumstead often finds occa- 
sion to question M. Cullerier's statements or inferences, 
and this he does in a short and forcible way which 
helps to kepp up the attention, and to make the book 
a verv readable one. — Brit, and For. Medico-Chir. 
Review, July, 1S69. 



// 



ILL {BERKELEY), 

Surgeon to the Lock Hospital, London. 

ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. 

one handsome octavo volume ; extra cloth, $3 25. (Lately Ptiblished.) 



In 



Bringing, as it does, the entire literature of the dis- 
ease down to the present day, and giving with great 
ability the results of modern research, it is in every 
respect a most desirable work, and one which should 
find a place in the library of every surgeon. — Cali- 
f>rnia Med. Gazette, June, 1S69. 

Considering the scope of the book and the careful 
attention to the manifold aspects and details of its 
subject, it is wonderfully concise. All these qualities 
render it an especially valuable book to the beginner, 
to whom we would most earnestly recommend its 
study ; while it is no less useful to the practitioner.— 
St. Louis Med. and Surg. Journal, May, 1S69. 



The author, from a vast amount of material, with 
all of which he was perfectly familiar, has under- 
taken to construct a new book, and has really suc- 
ceeded in producing a capital volume upon this 
subject. — Nashville Med. and Surg. Journal, May, 
1S69. 

The most convenient and readv book of reference 
we have met with.— N. Y. Med. Record, May 1, 1869. 

Most admirably arranged for both student and prac- 
titioner, no other work on the subject equals it ; it is 
more simple, more easily studied. — Buffalo Med. and 
Surg. Journal, March, 1S69. 



ALLEMAND AND WILSON. 

A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, 

AND TREATMENT OF SPERMATORRHOEA. By M. Lallemand. Fifth American 

edition. To which is added ON DISEASES OF THE VESICUL.E SEMINALES. 

By Marris Wilson, M.D. In one neat octavo volume, of about 400 pp., extra cloth, $2 75. 



20 



Henry C. Lea's Publications — (Diseases of the Skin). 



WILSON (ERASMUS), F.R.S. 

ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- 

enth American, from the sixth and enlarged English edition. In one large octavo volume 
of over 800 pages, $5. (Lately Published.) 

A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- 
EASES OP THE SKIN;" consisting of twenty beautifully executed plates, of which thir- 
teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, 
and embracing accurate representations of about one hundred varieties of disease, most of 
them the size of nature. Price, in extra cloth, $5 50. 
Also, the Text and Plates, bound in one handsome volume. Extra cloth, $10. 

From the Preface to the Sixth English Edition. 
The present edition has been carefully revised, in many parts rewritten, and our attention has 
been specially directed to the practical application and improvements of treatment. And, in 
conclusion, we venture to remark that if an acute and friendly critic should discover any differ- 
ence between our present opinions and those announced in former editions, we have only to ob- 
serve that science and knowledge are progressive, and that we have done our best to move onward 
with the times. 

The industry and care with which the author has revised the present edition are shown by the 
fact that the volume has been enlarged by more than a hundred pages. In its present improved 
form it will therefore doubtless retain the position which it has acquired as a standard and classical 
authority, while at the same time it has additional claims on the attention of the profession as 
the latest and most complete work on the subject in the English language. 

We can safely recommend it to the profession as 



Such a work as the one before us is a most capital 
and acceptable help. Mr. Wilson has long been held 
as high authority in this department of medicine, and 
his book on diseases of the skin has long been re- 
garded as one of the best text-books extant on the 
subject. The present edition is carefully prepared, 
and brought up in its revision to the present time. In 
this edition we have also included the beautiful series 
of plates illustrative of the text, and in the last edi- 
tion published separately. There are twenty of these 
plates, nearly all of them colored to nature, and ex- 
hibiting with great fidelity the various groups of 
diseases treated of in the body of the work. — Cin- 
cinnati Lancet, June, 1863. 

No one treating skin diseases should be without 
a copy of this standard work. — Canada Lancet. 
August, 1863. 

JftY THE SAME' AUTHOR. 



the best work on the subject now in existence in 
the English language. — Medical Times and Gazette. 

Mr. Wilson's volume is an excellent digest of the 
actual amount of knowledge of cutaneous diseases ; 
it includes almost every fact or opinion of importance 
connected with the anatomy and pathology of the 
skin.— British and Foreign Medical Review. 

These plates are very accurate, and are executed 
with an elegance and taste which are highly creditable 
to the artistic skill of the American artist whoexecuted 
them. — St. Louis Med. Journal. 

The drawings are very perfect, and the finish and 
coloring artistic and correct; the volume is au indis- 
pensable companion to the book it illustrates and 
completes. — Charleston Medical Journal. 



THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- 

eases op the skin. In one very handsome royal 12mo. volume. $3 50. (Lately Issued.) 



N 



ELIGAN (J. MOORE), M.D., M.R.I.A. 

A PRACTICAL TREATISE ON DISEASES OF THE SKIN 

Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M. D. 

In one neat royal 12mo. volume of 462 pages, extra cloth. $2 25. 
Fully equal to all the requirements of students and 
young practitioners. It is a work that h,as stood its 
ground, that was worthy the reputation of the au 



thor, and the high position of which has been main- 
tained by its learned editor. — Dublin Med. Press and 
Circular, Nov. 17, 1869. 

Of the remainder of the work we have nothing be- 
yond unqualified commendation to offer. It is so far 
the most complete one of its size that has appeared, 
and for the student there can be none which can com- 
pare with it in practical value. All the late disco- 
veries in Dermatology have been duly noticed, and 
their value justly estimated ; in a word, the work is 
T>Y THE SA3IE AUTHOR. _. 



fully up to the times, and is thoroughly stocked with 
most valuable information. — New York Med. Record, 
Jan. 15, 1867. 



This instructive little volume appeai-s once more. 
Since the death of its distinguished author, the study 
of skin diseases has been considerably advanced, and 
the results of these investigations have been added 
by the present editor to the original work of Dr. Neli- 
gan. This, however, has not so far increased its bulk 
as to destroy its reputation as the most convenient 
manual of diseases of the skin that can be procured 
by the student. — Chicago Med. Journal, Dec. 1S66. 



TLAS OF CUTANEOUS DISEASES. In one beautiful quarto 

presenting about one 'hundred varieties of 



volume, with exquisitely colored plates, &c 
disease. Extra cloth, $5 50. 
The diagnosis of eruptive disease, however, under 
all circumstances, is very difficult. Nevertheless, 
Dr. Neligan has certainly, "as far as possible," given 
a faithful and accurate representation of this class of 
diseases, and there can be no doubt that these plates 
will be of great use to the student and practitioner in 
drawing a diagnosis as to the class, order, and species 
to which the particular case may belong. While 
looking over the "Atlas" we have been induced to 
examine also the "Practical Treatise," and we are 



inclined to consider it a very superior work, com- 
bining accurate verbal description with sound views 
of the pathology and treatment of eruptive diseases. 
— Glasgow Med. Journal. 

A compend which will very much aid the practi- 
tioner in this difficult branch of diagnosis Taken 
with the beautiful plates of the Atlas, which are re- 
markable for their accuracy and beauty of coloring, 
it constitutes a very valuable addition to the library 
of a practical man. — Buffalo Med. Journal. 



TJILLIER [THOMAS), M.D. y 

•*--*- Physician to the Skin Department of University College Hospital, &c. 

HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. 

Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrations. 
Extra cloth, $2 25. (Just Issued.) 



Henry C. Lea's Publications — (Diseases of Children). 



21 



OMITH {J. LE WIS), M. D., 

*3 Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N. T. 

A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF 

CHILDREN. In one handsome octavo volume of 620 pages, extra cloth, $4 75 ; leather, 

$5 75. 

he has accustomed himself to take in the study of the 
significant facts relating to the pathological anatomy 
of the diseases of childhood, eminently fit him for the 
task which he has taken upon himself. The remark- 
able faculty of bringing out salient points and stating 
concisely other less important facts, enables him to 
crowd within a small compass a vast amount of prac- 
tical information. The attention given to the treat- 
ment of the various maladies, as well as the presenta- 
tion of all the recently accepted pathological views, 
make it one of the most valuable treatises, witliin its 
present compass, that can be placed in the hands of 
any seeker after truth. — N. Y. Med. Record, March 



We have no work upon the Diseases of Infancy and 
Childhood which can compare with it. — Buffalo Med. 
and Surg. Journal, March, 1869. 

The description of the pathology, symptoms, and 
treatment of the different diseases is excellent. — Am. 
Med. Journal, April, 1869. 

So full, satisfactory, and complete is the information 
to be derived from this work, that at no time have we 
examined the pages of any book with more pleasure. 
The diseases incident to childhood are treated with a 
clearness, precision, and understanding that is not 
often met with, and which must call forth the ap- 
proval of all who consult its pages. — Cincinnati Med. 
Repertory, May, 1869. 

The author of this volum is well known as a 
valued contributor to the literature of his specialty. 
The faithful manner in which he has worked in the 
public institutions with which he has been counected, 
the conscientious regard for truth which has for years 
characterized all his researches, the great amount of 
experience which he has been enabled to acquire in 
the treatment of infantile diseases, and the care which 



15, 1869. 

"We have perused Dr. Smith's book with not a little 
satisfaction; it is indeed an excellent work; well and 
correctly written ; thoroughly up to the modern ideas ; 
concise, yet complete in its material. We cannot help 
welcoming a work which will be worthy of reliance 
as a text-book for medical students and younger phy- 
sicians in their investigation of disease in children. 
Boston Med. and Surg. Journal, March 4, 1869. 



ffONDIE {D. FRANCIS), M.'D. 

^ A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. 

Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- 
printed pages, extra cloth, $5 25; leather, $6 25. (Lately Issued.) 

The present edition, which is the sixth, is fully up 
to the times in the discussion of all those points in the 
pathology and treatment of infantile diseases which 
have been brought forward by the Germau and French 
teachers. As a whole, however, the work is the best 
American one that we have, and in its special adapta- 
tion to American practitioners it certainly has no 
equal.— New York Med. Record, March 2, 1S68. 

No other treatise on this subject is better adapted 
to the American physician. Dr. Condie has long steod 
before his countrymen as one peculiarly pre-eminent 



in this department of medicine. His work has been 
so long a staudard for practitioners and medical stu- 
dents that we do no more now than refer to the fact 
that it has reached its sixth edition. We are glad 
once more to refresh the impressions of our earlier 
days by wandering through its pages, and at the same 
time to be able to recommend it to the youngest mem- 
bers of the profession, as well as to those who have 
the older editions on their shelves. — St. Louis Med. 
Reporter, Feb. 15, 1868. 



WE5T {CHARLES), M.D., 

' * Physician to the Hospital for Sick Children, &c. 

LECTURES ON THE DISEASES OF INFANCY AND CHILD- 

HOOD. Fourth American from the fifth revised and enlarged English edition. In one 
large and handsome octavo volume of 656 closely-printed pages. Extra cloth, $4 50 ; 
leather, $5 50. 



Of all the English writers on the diseases of chil- 
dren, there is no one so entirely satisfactory to us as 
Dr. West. For years we have held his opinion as 
judicial, an/1 have regarded him as one of the highest 
living authorities in the difficult department of medi- 
cal science in which he is most widely kuown. — 
Boston Med. and Surg. Journal, April 26, 1S66. 



Dr. West's volume is, in our opinion, incomparably 
the best authority upon the maladies of children 
that the practitioner can consult. — Cincinnati Jour, 
of Medicine, March, 1866. 

We have long regarded it as the most scientific and 
practical book on diseases of children which has yet 
appeared in this country.— Buffalo Medical Journal. 



s 



MITH (EUSTACE), 31. D., 

Physician to the Northwest London Free Dispensary for Sick Children. 

A PRACTICAL TREATISE ON THE WASTING DISEASES OF 

INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged 
English edition. In one handsome octavo volume, extra cloth, $2 50. (Now Ready.) 

a purpose of clinical usefulness, he has succeeded in 
producing a treatise on the causes of chronic wasting 
so complete that but little could be added, and yet so 
concise that it would be almost impossible to give a 
synopsis of his views in fewer words than the book 
itself contains.— N. Y. Med. Gazette, April 2, 1870. 



In this brief treatise, the author has made one o 
the most valuable contributions to medical literature 
that has been given to our profession for many years. 
To supply the want of information on this subject is 
the task which Dr. Smith has set himself, and admi- 
rably has he performed it. Keeping steadily iu view 



QVERSANT (P.), M. D., 

Honorary Surgeon to the Hospital for Sick Children, Paris. 

SURGICAL DISEASES OF INFANTS AND CHILDREN. Trans- 
lated by R. J. Dunglison, M. D. (To appear in the Medical News and Library for 
1871.) 
As this work embodies the experience of twenty years' service in the great Children's Hospital 
of Paris, it can hardly fail to maintain the reputation of the valuable practical series of volumes 
which have been laid before the subscribers of the " American Journal of the Medical Sci- 
encks." For terms, see p. 3. 

DEWEES ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN. Eleventh edition. 1 vol. 
8vo. of 548 pages. $2 SO. 



22 



Henry C. Lea's Publications — (Diseases of Women). 



/THOMAS {TGAILLARD),M.D., 

-*- Professor of Obstetrics, &c. in the College of Physicians and Surgeons, If. Y., &c. 

A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Se- 

cond edition, revised and improved In one large and handsome octavo volume of 650 
pages, with 225 illustrations, extra cloth, $5; leather, $6. 

From the Preface to the Second Edition. 
In a science so rapidly progressive as that of medicine, the profession has a rignt to expect that, 
when its approbation of a work is manifested by a call for a new edition, the author should re- 
spond by giving to his book whatever of additional value may be derivable from more extended 
experience, maturer thought, and the opportunity for correction. Fully sensible of this, the 
author of the present volume has sought by a careful revision of the whole, and by the addition 
of a chapter on Chlorosis, to render his work more worthy of the favor with which it has been 
received. — New York, March, 1869. 



If the excellence of a work is to be judged by its 
rapid sale, this one must take precedence of all others 
upon the same, or kindred subjects, as evidenced in 
the short time from its first appearance, in which a 
new edition is called for, resulting, as we are informed, 
from the exhaustion of the previous large edition. We 
deem it scarcely necessery to recommend this work 
to physicians as it is now widely known, and most 
of them already possess it, or will certainly do so. 
To students we unhesitatingly recommend it as the 
best text-hook on diseases of females extant. —St. Louis 
Med. Reporter, June, 1869. 

Of all the army of books that have appeared of late 
years, on the diseases of the uterus and its appendages, 
we know of none that is so clear, comprehensive, and 
practical as this of Dr. Thomas', or one that we should 
more emphatically recommend to the young practi- 
tioner, as his guide. — California Med. Gazette, June, 
1869. 

If not the best work extant on the subject of which 
it treats, it is certainly second to none other. So 
short a time has elapsed since the medical press 
teemed with commendatory notices of the first edition, 
that it would be superfluous to give an extended re- 
view of what is now firmly established as the American 
text-book of Gynaecology. — N^ Y. Med. Gazette, July 
17, 1869. 

This is a new and revised edition of a work which 
we recently noticed at some length, and earnestly 
commended to the favorable attention of our readers. 
The fact that, in the short space of one year, this 
second edition makes its appearance, shows that the 
general judgment of the profession has largely con- 
firmed the opinion we gave at that time. — Cincinnati 
Lancet, Aug. 1869. 

It is so short a time since we gave a full review of 
the first edition of this book, that we deem it only 
necessary now to call attention to the second appear- 
ance of the work. Its success has been remarkable, 
and we cau only congratulate the author on the 
brilliant reception his book has received. — If. Y. Med. 
Journal, April, 1S69. 



We regard this treatise as the one best adapted to 
serve as a text-book on gynsecology. — St. Louis Med. 
and Surg. Journal, May 10, 1S69. 

The whole work as it now stands is an absolute 
indispensable to any physician aspiring to treat the 
diseases of females with success, and according to the 
most fully accepted views of their aetiology and pa- 
thology. — Leavenworth Medical Herald, May, 1869. 

We have seldom read a medical book in which we 
found so much to praise, and so little — we can hardly 
say to object to — to mention with qualified commen- 
dation. We had proposed a somewhat extended 
review with copious extracts, but we hardly know 
where we should have space for it. We therefore 
content ourselves with expressing the belief that 
every practitioner of medicine would do well to pos- 
sess himself of the work. — Boston Med. and Surg. 
Journal, April 29, 1S69. 

The number of works published on diseases of 
women is large, not a few of which are very valuable. 
But of those' which are the most valuable we do not 
regard the work of Dr. Thomas as second to any. 
Without being prolix, it treats of the disorders to 
which it is devoted fully, perspicuously, and satisfac- 
torily. It will be found a treasury of knowledge to 
every physician who turns to its pages. We would 
like to make a number of quotations from the work 
of a practical bearing, but our space will not permit. 
The work should find a place in the libraries of all 
physicians.— Cincinnati Med. Repertory, May, 1869. 

No one will be surprised to learn that the valuable, 
readable, and thoroughly practical book of Professor 
Thomas has so soon advanced to a second edition. 
Although very little time has necessarily been allowed 
our author for revision and improvement of the work, 
he has performed it exceedingly well. Aside from 
the numerous corrections which he has found neces- 
sary to make, he has added an admirable chapter on 
chlorosis, which of itself is worth the cost of the 
volume.— -If. Y. Med. Record, May 15, 1S69. 



C 



RURCHILL {FLEETWOOD), M. D., M. R. I. A. 

ESSAYS ON THE PUERPERAL FEVER, AND OTHER DIS- 
EASES PECULIAR TO WOMEN. Selected from the writings of British Authors previ- 
ous to the close of the Eighteenth Century. In one neat octavo volume of about 450 
pages, extra cloth. $2 50. 



ASHWELL {SAMUEL), M.D., 

•*-*- Late Obstetric Physician and Lecturer at Guy^s Hospital. 

A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO 

WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third Ame- 
rican, from the Third and. revised London edition. In one octavo volume, extra cloth, of 
528 pages. $3 50. 

EIGBY ON THE CONSTITUTIONAL TREATMENT I MALES. With illustrations. Eleventh Edition, 

OF FEMALE DISEASES. In one neat royal 12mo | with the Author's last improvements and correc- 

volume, extra cloth, of about 250 pages. $1 00. tions. In one octavo volume of 536 pages, with 

DEWEES'S'TREATISE ON THE DISEASES OF FE- I P^tes, extra cloth, $3 00. 



J>ARNES {ROBERT), M. D., F. R. C.P., 

•*-* Obstetric Physician to St. Thomas' 1 Hospital, &c. 

A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. 

In one handsome octavo volume with illustrations. {Preparing.) 



Henry C. Lea's Publications — (Diseases of Women). 



23 



TTODGE {HUGH L.), M.D., 

J-*- Emeritus Professor of Obstetrics, &c, in the University of Pennsylvania. 

ON DISEASES PECULIAR TO WOMEN; including Displacements 

. of the Uterus. With original illustrations. Second edition, revised and enlarged. In 
one beautifully printed octavo volume of 531 pages, extra cloth. $4 50. {Lately Issued.) 
In the preparation of this edition the author has spared no pains to improve it with the results 
of his observation and study during the interval which has elapsed since the first appearance of 
the work. Considerable additions have thus been made to it, which have been partially accom- 
modated by an enlargement in the size of the page, to avoid increasing unduly the bulk of the 
volume. 



From Prof. W. H. Btford, of the Rush Medical 
College, Chicago. 

The book bears the impress of a master hand, and 
must, as its predecessor, prove acceptable to the pro- 
fession. In diseases of women Dr. Hodge has estab- 
lished a school of treatment that has become world- 
wide in fame. 

Professor Hodge's work is truly an original one 
from beginning to end, consequently no one can pe- 
ruse its pages without learning something new. The 
book, which is by no means a large one, is divided into 
two grand sections, so to speak : first, that treating of 
the nervous sympathies of the uterus, and, secondly, 
that which speaks of the mechanical treatment of dis- 
placements. of that organ. He is disposed, as a non- 
believer in the frequency of inflammations of the 



uterus, to take strong ground against many of the 
highest authorities in this branch of medicine, and 
the arguments which he offers in support of his posi- 
tion are, to say the least, well put. Numerous wood- 
cuts adorn this portion of the work, and add incalcu- 
lably to the proper appreciation of the variously 
shaped instruments referred to by our author. As a 
contribution to the study of women's diseases, it is of 
great value, and is abundantly able to stand on its 
own merits. — N. Y. Medical Record, Sept. 15, 1868. 

In this point of view, the treatise of Professor 
Hodge will be indispensable to every student in its 
department. The large, fair type and general perfec- 
tion of workmanship will render it doubly welcome 
— Pacific Med. and Surg. Journal, Oct. 1S68. 



WEST {CHARLES), 31. D. 

LECTURES OX THE DISEASES OF WOMEN. Third American, 

from the Third London edition. In one neat octavo volume of about 550 pages, extra 
cloth. $3 75 ; leather, $4 75. 
The reputation which this volume has acquired as a standard book of reference in its depart- 
ment, renders it only necessary to say that the present edition has received a careful revision at 
the hands of the author, resulting in a considerable increase of size. A few notices of previous 
editions are subjoined. 



The manner of the author is excellent, his descrip- 
tions graphic and perspicuous, and his treatment up 
to the level of the time— clear, precise, definite, and 
marked by strong common sense. — Chicago Med. 
Journal, Dec. 1861. 

We cannot too highly recommend this, the second 
edition of Dr. West's excellent lectures on the dis- 
eases of females.^ We know of no other book on this 
subject from which we have derived as much pleasure 
and instruction. Every page gives evidence of the 
honest, earnest, and diligent searcher after truth. He 
is not the mere compiler of other men's ideas, but his 
lectures are the result often years' patient investiga- 
tion in one of the widest fields for women's diseases — 
St. Bartholomew's Hospital. As a teacher, Dr. West 
is simple and earnest in his language, clear and com- 
prehensive in his perceptions, and logical in his de- 
ductions. — Cincinnati Lancet, Jan. 1S62. 

We return the author our grateful thanks for the 
vast amount of instruction he has afforded us. His 
valuable treatise needs no eulogy on our part. His 
graphic diction and truthful pictures of disease all 
speak for themselves. — Medico-Chirurg. Review. 

Most justly esteemed a standard work It 

bears evideuce of having been carefully revised, and 
is well worthy of the fame it has already obtained. 
—Dub. Med. Quar. Jour. 



As a writer. Dr. West stands, in our opinion, se- 
cond only to Watson, the "Macaulay of Medicine;" 
he possesses frhat happy faculty of clothing instruc- 
tion in easy garments; combining pleasure with 
profit, he leads his pupils, in spite of the ancient pro- 
verb, along a royal road to learning. His work is oue 
which will not satisfy the extreme on either side, but 
it is one that will please the great majority who are 
seeking truth, and one that will convince the student 
that he has committed himself to a candid, safe, and 
valuable guide. — N. A. Med.-Chirurg Review. 

We must now conclude this hastily written sketch 
with the confident assurance to our readers that the 
work will well repay perusal. The conscientious, 
painstaking, practical physician is apparent on every 
page. — N. Y. Journal of Medicine. 

We have to say of it, briefly and decidedly, that it 
is the best work on the subject in any language, and 
that it stamps Dr. West as the facile princeps of 
British obstetric authors. — Edinburgh Med. Journal. 

We gladly recommend his lectures as in the highest 
degree instructive to all who are interested in ob- 
stetric practice. — London. Lancet. 

We know of no treatise of the kind so complete, 
and yet so compact. — Chicago Med. Journal. 



J$Y THE SAME AUTHOR. 

AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF 

ULCERATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 25. 



IfEIGS {CHARLES D.), M. D.. 

-*■*-*- Late Professor of Obstetrics, &c. in Jefferson Medical College, Philadelphia. 

WOMAN: HER DISEASES AND THEIR REMEDIES. A Series 

of Lectures to his Class. Fourth and Improved edition. In one large and beautifully 
printed octavo volume of over 700 pages, extra cloth, $5 00; leather, $6 00. 
JDY THE SAME AUTHOR. 

ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED 

FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome 
octavo volume of 365 pages, extra cloth. $2 00. 



s 



IMPSON {SIR JAMES F.), M.D. 

CLINICAL LECTURES ON THE DISEASES OF WOMEN. With 

numerous illustrations. In one octavo volume of over 500 pages. Seoond edition, preparing. 



24 



Henry C. Lea's Publications — {Midwifery). 



JJODGE (HUGH L.), M.D., 

Emeritus Professor of Midwifery, &c. in the University of Pennsylvania, &c. 

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 
trated with large lithographic plates containing one hundred and fifty-nine figures from 
original photographs, and with numerous wood-cuts. In one large and beautifully printed 
quarto volume of 550 double-columned pages, strongly bound in extra cloth, $14. 
The work of Dr. Hodge is something more than a 
6imple presentation of his particular views in the de- 
partment of Obstetrics ; it is something more than an 
ordinary treatise on midwifery; it is, in fact, a cyclo- 
paedia of midwifery. He has aimed to embody 



single volume the whole science and art of Obstetrics. 
An elaborate text is combined with accurate and va- 
ried pictorial illustrations, so that no fact or principle 
is left unstated or unexplained. — Am. Med. Times, 
Sept. 3, 1864. 

We should like to analyze the remainder of this 
excellent work, but already has this review extended 
beyoud our limited space. We cannot conclude this 
notice without referring to the excellent finish of the 
work. In typography it is not to be excelled ; the 
paper is superior to what is usually afforded by our 
American cousins, quite equal to the best of English 
books. The engravings and lithographs are most 
beautifully executed. The work recommends itself 
for its originality, and is in every way a most valu- 
able addition to those on the subject of obstetrics.. — 
Canada Med. Journal, Oct. 1S64. 

It is very large, profusely and elegantly illustrated, 
and is fitted to take its place near the works of great 
obstetricians. Of the American works on the subject 
it is decidedly the best. — Edinb. Med. Jour., Dec. '64. 

'•* 
on receipt of six cents in postage stamps. 



We have examined Professor Hodge's work with 
great satisfaction ; every topic is elaborated most 
fully. The views of the author are comprehensive, 
and concisely stated. The rules of practice are judi- 
cious, and will enable the practitioner to meet every 
emergency of obstetric complication with confidence. 
— Chicago Med. Journal, Aug. 1864. 

More time than we have had at our disposal since 
we received the great work of Dr. Hodge is necessary 
to do it justice. It is undoubtedly by far the most 
original, complete, and carefully composed treatise 
on the principles and practice of Obstetrics which has 
ever been issued from the American press. — Pacific 
Med. and Surg. Journal, July, 1S64. 

We have read Dr. Hodge's book with great plea- 
sure, and have much satisfaction in expressing our 
commendation of it as a whole. It is certainly highly 
instructive, and in the main, we believe, correct. The 
great attention which the author has devoted to the 
mechanism of parturition, taken along with the con- 
clusions at which he has arrived, point, we think, 
conclusively to the fact that, in Britain at least, the 
doctrines of Naegele have been too blindly received. 
— Glasgow Med. Journal, Oct. 1864. 



/J1ANNER [THOMAS H.), M. D. 

ON THE SIGNS AND DISEASES OF PREGNANCY. First American 

from the Second and Enlarged English Edition. With four colored plates and illustrations 
on wood. In one handsome octavo volume of about 500 pages, extra cloth, $4 25. 



The very thorough revision the work has undergone 
has added greatly to its practical value, and increased 
materially its efficiency as a guide to the student and 
to the voung practitioner. — Am. Journ. Med. Sci., 
April, 1S6S. 

With the immense variety of subjects treated of 
and the ground which they are made to cover, the im- 
possibility of giving an extended review of this truly 
remarkable work must be apparent. We have not a 
single fault to find with it, and most heartily com- 
mend it to the careful study of every physician who 
would not only always be sure of his diagnosis of 
pregnancy, but always ready to treat all the nume- 
rous ailments that are, unfortunately for the civilized 
women of to-day, so commonly associated with the 
function.— N. Y. Med. Record, March 16, 1868. 

We have much pleasure in calling the attention of 
our readers to the volume produced by Dr. Tanner, 
the second edition of a work that was, in its original 



state even, acceptable to the profession. We recom- 
mend obstetrical students, young and old, to have 
this volume in their collections. It contains not only 
a fair statement of the signs, symptoms, and diseases 
of pregnancy, but comprises in addition much inter- 
esting relative matter that is not to be found in any 
other work that we can name. — Edinburgh Med. 
Journal, Jan. 1868. 

In its treatment of the signs and diseases of preg- 
nancy it is the most complete book we know of, 
abounding on every page with matter valuable to the 
general practitioner. — Cincinnati Med. Repertory, 
March, 1868. 

This is a most excellent work, and should be on the 
table or in the library of every practitioner. — Hum- 
boldt Med. Archives, Feb. 1868. 

A valuable compendium, enriched by his own la- 
bors, of all that is known on the signs and diseases of 
pregnancy.— St. Louis Med. Reporter, Feb. 15, 1868. 



s 



WAYNE [JOSEPH GRIFFITHS), M. D., 

Physician-Accoucheur to the British General Hospital, &c. 

OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 
MENCING MIDWIFERY PRACTICE. From the Fourth and Revised London Edition, 
with Additions by E. R. Hutchins, M. D. With Illustrations. In one neat 12mo. vol- 
ume. Extra cloth, $1 25. (Just Issued.) 

answers the purpose. It is not only valuable for 
young beginners, but no one who is not a proficient 
in the art of obstetrics should be without it, because 
it condenses all that is necessary to know for ordi- 
nary midwifery practice. We commend the book 
most favorably.— ££. Louis Med. and Surg. Journal, 
Sept. 10, 1870. 



It is really a capital little compendium of the sub- 
ject, and we recommend young practitioners to buy it 
and carry it with them when called to attend cases of 
labor. They cau while away the otherwise tedious 
hours of waiting, and thoroughly fix in their memo- 
ries the most important practical suggestions it con- 
tains. The American editor has materially added by 
his notes and the concluding chapters to the com- 
pleteness and general value of the book. — Chicago 
Med. Journal, Feb. 1870. 

The manual before us contains in exceedingly small 
compass — small enough to carry in the pocket — about 
all there is of obstetrics, condensed into a nutshell of 
Aphorisms. The illustrations are well selected, and 
serve as excellent reminders of the conduct of labor — 
regular and difficult. — Cincinnati Lancet, April, '70. 

This is a most admirable little work, and completely 



A studied perusal of this little book has satisfied 
us of its eminently practical value. The object of the 
work, the author says, in his^preface, is to give the 
student a few brief and practical directions respect- 
ing the management of ordinary cases of labor ; and 
also to poiut out to him in extraordinary cases when 
and how he may act upon his own responsibility, and 
when he ought to send for assistance. — iV. T. Medical 
Journal, May, 1870. 



Henry C. Lea's Publications — {Midwifery). 



25 



li/fEIGS [CHARLES D.), M.D., 

•*■!*■ Lately Professor of Obstetrics, &c, in the Jefferson Medical College, Philadelphia. 

OBSTETRICS: THE SCIENCE AND THE ART. Fifth edition, 

revised. With one hundred and thirty illustrations. In one beautifully printed octavo 
volume of 760 large pages. Extra cloth, $5 50; leather, $6 50. 



It is to the student that our author has more par- 
ticularly addressed himself; but to the practitioner 
we believe it would be equally serviceable as a book 
of reference. No work that we have met with so 
thoroughly details everything that falls to the lot of 
the accoucheur to perform. Every detail, no matter 
how minute or how trivial, has found a place.— 
Canada Medical Journal, July, 1867. 

The original edition is already so extensively and 



favorably known to the profession that no recom- 
mendation is necessary; it is sufficient to say, the 
present edition is very much extended, improved, 
and perfected. Whilst the great practical talents and 
unlimited experience of the author render it a most 
valuable acquisition to the practitioner, it is so con- 
densed as to constitute a most eligible and excellent 
text-book for the student. — Soutliern Med. and Surg, 
journal, July, 1867. 



R 



AMSBOTHAM [FRANCIS H.), M.D. 

THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 

CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged 
edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia. In one large 
and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
bands; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
all nearly 200 large and beautiful figures. $7 00. 

To the physician's library it is indispensable, while 
to the student, as a text-book, from which to extract 
the material for laying the foundation of an ed ucation 
on obstetrical science, it has no superior. — Ohio Mtd. 
and Surg. Journal. 

When we call to mind the toil we underwent in 
acquiring a knowledge of this subject, we cannot but 
envy the student of the present day the aid which 
this work will afford him. — Am. Jour, of the Med. 
Sciences. 



We will only add that the student will learn from 
it all he need to know, and the practitioner will find 
it, as a book of reference, surpassed by none other. — 
Stethoscope. 

The character and merits of Dr. Ramsbotham's 
work are so well known and thoroughly established, 
that comment is unnecessary and praise superfluous. 
The illustrations, which are numerous and accurate, 
are executed in the highest style of art. We cannot 
too highly recommend the work to our readers. — St. 
Louis Med. and Surg. Journal. 



fJHURCHILL (FLEETWOOD), M.B., M.R.I. A. 

ON THE THEORY AND PRACTICE OF MIDWIFERY. A new 

American from the fourth revised and enlarged London edition. With notes and additions 
by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Chil- 
dren," Ac. With one hundred and ninety-four illustrations. In one very handsome octavo 
volume of nearly 700 large pages. Extra cloth, $4 00; leather, $5 00. 
In adapting this standard favorite to the wants of the profession in the United States, the editor 
has endeavored to insert everything that his experience has shown him would be desirable for the 
American student, including a large number of illustrations. With the sanction of the author, 
he has added, in the form of an appendix, some chapters from a little "Manual for Midwives and 
Nurses," recently issued by Dr. Churchill, believing that the details there presented can hardly 
fail to prove of advantage to the junior practitioner. The result of all these additions is that the 
work now contains fully one-half more matter than the last American edition, with nearly one- 
half more illustrations; so that, notwithstanding the use of a smaller type, the volume contains 
almost two hundred pages more than before. 



These additions render the work still more com- 
plete and acceptable than ever; and with the excel- 
lent style in which the publishers have presented 
this edition of Churchill, we can commend it to the 
profession with great cordiality and pleasure. — Cin- 
cinnati Lancet. 

Few work? on this branch of medical science are 
equal to it, certainly none excel it, whether in regard 
to theory or practice, and in one respect it is superior 
to all others, viz., in its statistical information, and 
therefore, on these grounds a most valuable work for 
the physician, student, or lecturer, all of whom will 
find in it the information which they are seeking. — 
Brit. Am. Journal. 

The present treatise is very much enlarged and 
amplified beyond the previous editions but nothing 



has been added which could be well dispensed with. 
An examination of the table of contents shows how 
thoroughly the author has gone over the ground, and 
the care he has taken in the text to present the sub- 
jects in all their bearings, will render this new edition 
even more necessary to the obstetric student than 
were either of the former editions at the date of their 
appearance. No treatise on obstetrics with which we 
are acquainted can compare favorably with this, in 
respect to the amount of material which has been 
gathered from every source. — Boston Mtd. and Surg. 
Journal. 

There is no better text-book for students, or work 
of reference and study for the practising physician 
than this. It should adorn and enrich every medical 
library. — Chicago Med. Journal. 



31 



ONTGOMERY [W. F.), M.D., 

Professor of Midwifery in the King's and Queen's College of Physicians in Ireland. 

AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREG- 

NANCY. With some other Papers on Subjects connected with Midwifery. From the second 
and enlarged English edition. With two exquisite colored plates, and numerous wood-cuta. 
In one very handsome octavo volume of nearly 600 pages, extra cloth. $3 75. 



RIGBT'S SYSTEM OF MIDWIFERY. With, Notes 
and Additional Illustrations. Second American 
edition. One volume octavo, extra cloth, 422 pages. 
$2 50. 



DEWEES'S COMPREHENSIVE SYSTEM OF MID- 
WIFERY. Twelfth edition, with the author's last 
improvements and corrections. In one octavo vol- 
ume, extra cloth, of 600 pages. $3 50. 



26 



Henry C. Lea's Publications — (Surgery). 



(1ROSS {SAMUEL D.), M.D., 

v>* Professor of Surgery in the Jefferson Medical College of Philadelphia. 

A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, 

and Operative. Illustrated by upwards of Thirteen Hundred Engravings. Fourth edition, 
carefully revised, and improved. In two large and beautifully printed royal octavo volumes 
of 2200 pages, strongly bound in leather, with raised bands. $15 00. 
The continued favor, shown by the exhaustion of successive large editions of this great work, 
proves that it has successfully supplied a want felt by American practitioners and students. Though 
but little over six years have elapsed since its first publication, it has already reached its fourth 
edition, while the care of the author in its revision and correction has kept it in a constantly im- 
proved shape. By the use of a close, though very legible type, an unusually large amount of 
matter is condensed in its pages, the two volumes containing as much as four or five ordinary 
octavos. This, combined with the most careful mechanical execution, and its very durable binding, 
renders it one of the cheapest works accessible to the profession. Every subject properly belonging 
to the domain of surgery is treated in detail, so that the student who possesses this work may be 
said to have in it a surgical library. 



It must long remain the most comprehensive work 
on this important part of medicine. — Boston Medical 
and, Surgical Journal, March 23, 1865. 

We have compared it with most of our standard 
works, such as those of Erichsen, Miller, Fergusson, 
Syme, and others, and we must, in justice to our 
author, award it the pre-eminence. As a work, com- 
plete iu almost every detail, no matter how minute 
or trifling, and embracing every subject known in 
the principles and practice of surgery, we believe it 
stands without a rival. Dr. Gross, in his preface, re- 
marks "my aim has been to embrace the whole do- 
main of surgery, and to allot to every subject its 
legitimate claim to notice;" and, we assure our 
readers, he has kept his word. It is a work which 
we can most confidently recommend to our brethren, 
for its utility is becoming the more evident the longer 
it is upon the shelves of our library. — Canada Med. 
Journal, September, 1865. 

The first two editions of Professor Gross' System of 
Surgery are so well known to the profession, and so 
highly prized, that it would be idle for us to speak in 
praise of this work.— Chicago Medical Journal, 
September, 1865. 

We gladly indorse the favorable recommendation 
of the work, both as regards matter and style, which 
we made when noticing its first appearance.— British 
and Foreign Medico-Chirurgical Review, Oct. 1865. 

The most complete work that has yet issued from 
the press on the science and practice of surgery. — 
London Lancet. 

This system of surgery is, we predict, destined to 
take a commanding position in our surgical litera- 
ture, and be the crowning glory of the author's well 
earned fame. As an authority on general surgical 
subjects, this work is long to occupy a pre-eminent 
place, not only at home, but abroad. We have no. 
hesitation in pronouncing it without a rival in our 
language, and equal to the best systems of surgery in 
any language. — N. T. Med. Journal. 

Not only by far the best text-book on the subject, 
as a whole, within the reach of American students, 
but one which will be much more than ever likely 
to be resorted to and regarded as a high authority 
abroad. — Am. Journal Med. Sciences, Jan. 1865. 

The work contains everything, minor and major, 
operative and diagnostic, including mensuration and 
examination, venereal diseases, and uterine manipu- 
lations and operations. It is a complete Thesaurus 
of modern surgery, where the student and practi- 



tioner shall not seek in vain for what they desire. — 
San Francisco Med. Press, Jan. 1865. 

Open it where we may, we find sound practical in- 
formation conveyed in plain language. This book is 
no mere provincial or even national system of sur- 
gery, but a work which, while very largely indebted 
to the past, has a strong claim on the gratitude of the 
future of surgical science. — Edinburgh Med. Journal, 
Jan. 1865. 

A glance at the work is sufficient to show that the 
author and publisher have spared no labor in making 
it the most complete "System of Surgery" ever pub- 
lished in any country.— St. Louis Med. and Surg 
Journal, April, 1865. 

The third opportunity is now offered during our 
editorial life to review, or rather to indorse and re- 
commend this great American work on Surgery. 
Upon this last edition a great amount of labor has 
been expended, though to all others except the author 
the work was regarded in its previous editions as so 
full and complete as to be hardly capable of improve- 
ment. Every chapter has been revised ; the text aug- 
mented by nearly two hundred pages, and a con- 
siderable number of wood-cuts have been introduced. 
Many portions have been entirely re-written, and the 
additions made to the text are principally of a prac- 
tical character. This comprehensive treatise upon 
surgery has undergone revisions and enlargements, 
keeping pace with the progress of the art and science 
of surgery, so that whoever is in possession of this 
work may consult its pages upon any topic embraced 
within the scope of its department, and rest satisfied 
that its teachiug is fully up to the present standard 
of surgical knowledge. It is also so comprehensive 
that it may truthfully be said to embrace all that is 
actually known, that is really of any value in the 
diagnosis and treatment of surgical diseases and acci- 
dents. Wherever illustration will add clearness to the 
subject, or make better or more lasting impression, it 
is not wanting; in this respect the work is eminently 
superior. — Buffalo Med. Journal, Dec. 1864. 

A system of surgery which we think unrivalled in 
our language, and which will indelibly associate his 
name with surgical science. And what, in our opin- 
ion, enhances the value of the work is that, while the 
practising surgeon will find all that he requires in it, 
it is at the same time one of the most valuable trea- 
tises which can be put into the hands of the student 
seeking to know the principles and practice of this 
branch of the profession which he designs subse- 
quently to follow. — Tlie Brit. Am. Journ., Montreal. 



DY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON FOREIGN BODIES IN THE 

AIR-PASSAGES. In one handsome octavo volume, extra cloth, with illustrations, 
pp. 468. $2 75. 

SKET'S OPERATIVE SUKGERT. In one very handsome octavo volume, extra cloth, of over 650 pages ; 
with about 100 wood-cuts. $3 25. 



A 



SHHURST {JOHN, Jr.), M. D., 

Surgeon to the Episcopal Hospital, Philadelphia. 

THE PRINCIPLES AND PRACTIQE OF SURGERY. For the 

use of Students and Practitioners. In one very handsome octavo volume, with several 
hundred illustrations. {Preparing.) 



Henry C. Lea's Publications — (Surgery). 2T 

ffRICHSEN {JOHN), 

•U Senior Surgeon to University College Hospital. 

THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- 

gical Injuries, Diseases, and Operations. From the Fifth enlarged and carefully revised 

London Edition. With Additions by John Ashhurst, Jr., M. D., Surgeon to the Episcopal 

Hospital, &c. Illustrated by over six hundred Engravings on wood. In one very large 

and beautifully printed imperial, octavo volume, containing pver twelve hundred closely 

printed pages : cloth, $7 50 ; leather, raised bands, $8 50. (Jtist Issued.) ^ 

This volume having enjoyed repeated revisions at the hands of the author has been greatly 

enlarged, and the present edition will thus be found to contain at least one-half more matter than 

the last American impression. On the latest London edition, just issued, especial care has been 

bestowed. Besides the most minute attention on the part of the author to bring every portion of 

it thoroughly on a level with the existing condition of science, he called to his aid gentlemen of 

distinction in special departments. Thus a chapter on the Surgery of the Eye and its Appendages 

has been contributed by Mr. Streatfeild ; the section devoted to Syphilis has been rearranged 

under the supervision of Mr. Berkeley Hill ; the subjects of General Surgical Diseases, including 

Pyaemia, Scrofula, and Tumors, have been revised by Mr. Alexander Bruce ; and other professional 

men of eminence have assisted in other branches. The work may thus be regarded as embodying 

a complete and comprehensive view of the most advanced condition of British surgery ; while 

such omissions of practical details in American surgery as were found have been supplied by the 

editor, Dr. Ashhurst. 

Thus complete in every respect, thoroughly illustrated, and containing in one beautifully printed 
volume the matter of two or three ordinary octavos, it is presented at a price which renders it 
one of the cheapest works now accessible to the profession. A continuance of the very remarkable 
favor which it has thus far enjoyed is therefore confidently expected. 



The high position which Mr. Evichsen's Science and 
Art of Surgery has for some time attained, not only 
in this country, but on the Continent and in America, 
almost limits the task of the reviewer, on the appear- 
ance of a new edition, to the mere announcement. 
Elaborate analysis and criticism would be out of 
place ; and nothing remains to be done except to state 
in general terms that the author has bestowed on it 
that labor which such a work required in order to be 
made a representative of the existing state of surgical 
science and practice. Of the merits of the book as a 
guide to the "Science and Art of Surgery" it is not 
necessary for us to say much. Mr. Erichsen is one of 



those enlightened surgeons of the present day, who 
regard an acquaintance with the manual part of sur- 
gery as only a portion of that knowledge which a 
surgeon should possess.— British Medical Journal, 
Jan. 2, 1869. 

Thus the work bears in every feature a stamp of 
novelty and freshness which will commend it to tho*e 
who are making its acquaintance for the fiist time, 
whilst those who have found it a safe guide aud 
friend in former years will be able to refer to the new 
edition for the latest information upon any point of 
surgical controversy. — London Lancet, Jan. 23, -1869. 



JDT THE SAME AUTHOR. (Just Issued.) 

ON RAILWAY, AND OTHER INJURIES OF THE NERVOUS 



SYSTEM. In small octavo volume. Extra cloth, $1 00. 



M 



B 



ILLER {JAMES), 

Late Professor of Surgery in the University of Edinburgh, &c. 

PRINCIPLES OF SURGERY. Fourth American, from the third and 

revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with 
two hundred and forty illustrations on wood, extra cloth. $3 75. 
Y THE SAME AUTHOR. 

THE PRACTICE OF SURGERY. Fourth American, from the last 

Edinburgh edition. Revised by the American editor. Illustrated by three hundred and 

sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, extra 

cloth. $3 75. 

It is seldom that two volumes have ever made so I acquired. The author is an eminently sensible, prae- 

profcund an impression in so short a time as the | tical, and well-informed man, who knows exactly 

'"Principles" and the "Practice"' of Surgery by Mr. I what he is talking about and exactly how to talk it. — 

Miller, or so richly merited the reputation they have | Kentucky Medical Recorder. 



piRRIE ( WILLIAM), F. R. S. E., 

-*- Professor of Surgery in the University of Aberdeen. 

THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by 

John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the 
Pennsylvania Hospital, <fcc. In one very handsome octavo volume of 780 pages, with 316 
illustrations, extra cloth. $3 75. 



VARGENT (F. W.), M.D. 



ON BANDAGING AND OTHER OPERATIONS OF MINOR SUR- 

GERY. New edition, with an additional chapter on Military Surgery. One handsome royal 

12mo. volume, of nearly 400 pages, with 184 wood-cuts Extra cloth, $1 75. 

Exceedingly convenient and valuable to all mem- I We cordially commend this volume as one which 

bers of the profession.— Chicago Medical Examiner, \ the medical student should most closely study; and 

May, lS(i2. i to the surgeon in practice it must prove itself instruct- 



The verv best manual of Minor Surgery we have ivf " on man y P oiut8 which he may have forgotten.— 
seen.— Buffalo Medical Journal. I Brit - Am - Journal, Say. 1862. 



28 



Henry C. Lea's Publications — (Surgery). 



jnRUITT {ROBERT), M.R.C.S., Src. 



THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 

A new and revised American, from the eighth enlarged and improved London edition. Illus- 
trated with four hundred and thirty -two wood-engravings. In one very handsome octavo 
volume, of nearly 700 large and closely printed pages. Extra cloth, $4 00 ; leather, $5 00. 
All that the surgical student or practitioner could theoretical surgical opinions, no -work that we are at 

present acquainted with can at all compare with it. 



desire. — Dublin Quarterly Journal. 

It is a most admirable book. We do not know 
when we have examined one with more pleasure.— 
Boston Med. and Surg. Journal. 

In Mr. Druitt's book, though containing only some 
seven hundred pages, both the principles and the 
practice of surgery are treated, and so clearly and 
perspicuously, as to elucidate every important topic. 
The fact that twelve editions have already been called 



It is a compendium of surgical theory (if we may use 
the word) and practice in itself, and well deserves 
the estimate placed upon it. — Brit. Am. Journal. 

Thus enlarged and improved, it will continue to 
rank among our best text-books on elementary sur- 
gery. — Columbus Rev. of Med. and Surg. 

We must close this brief notice of an admirable 
work by recommending it to the earnest attention of 



for, in these days of active competition, would of every medical student. — Charleston Medical Journal 
itself show it to possess marked superiority. We [ and Review! 

have examined the book most thoroughly, and can i A text-book which the general voice of the profes- 
say that this success is well merited His book I 8iojl in both Eng i and ana America has commended as 
moreover, possesses the inestimable advantages of j one of ^ most admirable "manuals," or, "va<U 
having the subjects perfectly well arranged and clas- I mecum » as its English title runs, which can be 
sifled, and of being written in a style at once clear p i ace <i j n t he hands of the student, The merits of 
and succinct.— Am. Journal of Med. Sciences. | D ru iU's Surgery are too well known to every one to 

Whether we view Druitt's Surgery as a guide to j need any further eulogium from us. — Nashville Med. 
operative procedures, or as representing the latest ! Journal. 



HAMILTON {FRANK R.), M.D., 



Professor of Fractures and Dislocations, &c. in Bellevue Hosp. Med. College, New Yorlt. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 
TIONS. Third edition, thoroughly revised. In one large and handsome octavo volume 
of 777 pages, with 294 illustrations, extra cloth, $5 75. 
In fulness of detail, simplicity of arrangement, and American professor of surgery; and his book adds 
accuracy of description, this work stands unrivalled. Jone more to the list of excellent practical works which 
So far as we know, no other work on the subject in jhave emanated from his country, notices of which 
the English language can be compared with it. While have appeared from time to time in our columns du- 
congratulating our trans-Atlantic brethren on the ring the last few months.— London Lancet, Dec. 15, 
European reputation which Dr. Hamilton, along with 1 1S66. 

many other American surgeons, has attained, we also These additions make the work much more valua- 
may be proud that, in the mother tongue, a classical ble, and it must be accepted as the most complete 



monograph on the subject, certainly in our own, if 
not even in any other language.— American Journal 
Med. Sciences, Jan. 1867. 



work has been produced which need not fear compa 
rison with the standard treatises of any other nation 
—Edinburgh Med. Journal, Dec. 1866, 

The credit of giving to the profession the only com- This is the most complete treatise on the subject in 
plete practical treatise on fractures and dislocations English language.- i^mfrmp's^crac*, Jan.1867 
in our language during the present century, belongs! A mirror of all that is valuable in modern surgery, 
to the author of the work before us, a distinguished Richmond Med. Journal, Nov. 1866. 



BRODIE'S CLINICAL LECTURES ON SURGERY. 
1 vol. Svo., 350 pp.; cloth, $1 25. 

COOPER'S LECTURES ON THE PRINCIPLES AND 
Practice of Surgery. In one very large octavo 
volume, extra cloth, of 750 pages. $2 00. 



GIBSON'S INSTITUTES AND PRACTICE OF SUR- 
GERY. Eighth edition, improved and altered. With> 
thirty-four plates. In two handsome octavo vol-^ 
umes, about 1000 pp., leather, raised bands. $6 50. 

MACKENZIE ON DISEASES AND INJURIES OP 
THE EYE. 1 vol. 8vo., 1027 pp., extra cloth. $6. 



ASHTON {T. J.). 
ON THE DISEASES, INJURIES, AND MALFORMATIONS OF 

THE RECTUM AND ANUS; with remarks on Habitual Constipation. Second American, 
from the fourth and enlarged London edition. With handsome illustrations. In one very 
beautifully printed octavo volume of about 300 pages. $3 25. 

The short period which has elapsed since the ap- 
pearance of the former American reprint, and the 
numerous editions published in England, are the best 
arguments we can offer of the merits, and of the use- 
lessness of any commendation on our part of a bouk 
already so favorably known to our readers. — Boston 
Med. and Surg. Journal, Jan. 25, 1866. 



We can recommend this volume of Mr Ashton's in 
the strongest terms, as containing all the latest details 
of the pathology and treatment of diseases connected 
with the rectum. — Canada Med. Journ., March, 1866. 

One of the most valuable special treatises that the 
physician and surgeon can have in his library.— 
Chicago Medical Examiner, Jan 



1S66. 



M 



ORLAND (W. W.), M.D. 

DISEASES OF THE URINARY ORGANS; a Compendium of their 

Diagnosis, Pathology, and Treatment. With illustrations In one large and handsome 
octar* volume of about 600 pages, extra cloth. $3 50. 



T>RYANT {THOMAS), F.R.C.S. 

THE PRACTICE OF SURGERY. A Manual, with numerous 

engravings on wood. In one very handsome volume. {Preparing.) 



Henry C. Lea's Publications — (Surgery). 



29 



w 



ELLS {J. SOELBERG), 

Professor of Ophthalmology in King's College Hospital, &e. 



A TREATISE ON DISEASES OF THE EYE. First American 

Edition, with additions ; illustrated with 216 engravings on wood, and six colored plates. 

Together with selections from the Test-types of Jaeger and Snellen. In one large and 

very handsome octavo volume of about 750 pages : extra cloth, $5 00 ; leather, $6 00. 

(Lately Issued.) 
A work has long been wanting which should represent adequately and completely the present 
aspect of British Ophthalmology, and this want it has been the aim of Mr. Wells to supply. The 
favorable reception of his volume by the medical press is a guarantee that he has succeeded in 
his undertaking, and in reproducing the work in this country every effort has been made to 
render it in every way suited to the wants of the American practitioner. Such additions as 
seemed desirable have been introduced by the editor, Dr. I. Minis Hays, and the number of 
illustrations has been more than doubled. The importance of test-types as an aid to diagnosis 
is so universally acknowledged at the present day that it seemed essential to the completeness of 
the work that they should be added, and as the author recommends the use of those both of Jaeger 
and of Snellen for different purposes, selections have been made from each, so that the practitioner 
may have at command all the assistance necessary. The work is thus presented as in every way 
fitted to merit the confidence of the American profession. 

His chapters are eminently readable. His style is 
clear and flowing. He can be short without over-con- 
densing, and accurate without hair splitting. These 
merits appear in a remarkable degree when he comes 
to treat of the more abstruse departments of his sub 



ject, and contrast favorably with the labored obscurity 
which mars the writings of some greater authorities 
in the same line. We congratulate Mr. Wells upon 
the success with which he has fulfilled his ideal, as 



represented in the preface, in producing " an English 
treatise on the diseases of the eye, which should 
embrace the modern doctrines and pi-actice of the 
British and Foreign Schools of Ophthalmology." The 
new school of Ophthalmology may also be congratu- 
lated in having found an exponent who is neither a 
bigoted partisan of everything new, nor a scoffer at 
everything old. — Glasgow Med. Journal, May, 1869. 



ffOYNBEE {JOSEPH), F.R.S., 

•*- Aural Surgeon to and Lecturer on Surgery at St. Mary's Hospital. 

THE DISEASES OF THE EAR: their Nature, Diagnosis, and Treat- 
ment. With one hundred engravings on wood. Second American edition. In one very 
handsomely printed octavo volume of 440 pages ; extra cloth, $4. 
The appearance of a volume of Mr. Toynbee's, there- 
fore, in which the subject of aural disease is treated 
in the most scientific manner, and our knowledge in 
respect to it placed fully on a par with that which 
we possess respecting most other organs of the body, 
is a matter for sincere congratulation. We may rea- 
sonably hope that henceforth the subject of this trea- 
tise will cease to be among the opprobria of medical 
science. — London Medical Review. 



The work, as was stated at the outset o f our notice, 
is a model of its kind, and every page and paragraph 
of it are worthy of the most thorough study. Con- 
sidered all in all — as an original work, well written, 
philosophically elaborated, and happily illustrated 
with cases and drawings — it is by far the ablest mo- 
nograph that has ever appeared on the anatomy and 
diseases of the ear, and one of the most valuable con- 
tributions to the art and science of surgery in the 
nineteenth century.— N. Am. Med.-Chirurg. Review. 



TA URENCE {JOHN Z.), F. R. C. S. 

Editor of the Ophthalmic Review, &c. 

A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of 

Practitioners. Second Edition, revised and enlarged. With numerous illustrations. 

one very handsome octavo volume, extra cloth, $3 00. {Lately Issued.) 
No book on ophthalmic surgery was more needed. 
Designed, as it is, for the wants of the busy practi- 
tioner, it is the neplus ultra- of perfection. It epito- 
mizes all the diseases incidental to the eye in a clear 



In 



and masterly manner, not only enabling the practi 
tioner readily to diagnose each variety of disease, but 
affording him the more important assistance of proper 
treatment. Altogether this is a work which ought 
certainly to be in the hands of every general practi- 
tioner. — Dublin Med. Press and Circular, Sept. 12, '66. 
We cordially recommend this book to the notice of 
our readers, as containing an excellent outline of 
modern ophthalmic surgery. — British Med. Journal, 
October 13, 1866. 



Not only, as its modest title suggests, a "Handy- 
Book" of Ophthalmic Surgery, but an excellent and 
well-digested resume of all that is of practical value 
iu the specialty. — New York Medical Journal, No- 
vember, 1S66. 



This object the authors have accomplished in a 
highly satisfactory manner, and we know no work 
we can more highly recommend to the "busy practi- 
tioner" who wishes to make himself acquainted with 
the recent improvements in ophthalmic science. Such 
a work as this was much wanted at this time, and 
this want Messrs. Laurence and Moon have now well 
supplied.— Am. Journal Med. Sciences, Jan. 1S67. 



TA WSON {GEORGE), F. R. C. S, Engl, 

•*-^ Assistant Surgeon to the Royal London Ophthalmic Hospital, Moorfields, &c. 

INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- 

diate and Remote Effects. With about one hundred illustrations. In one very hand- 
some octavo volume, extra cloth, $3 50 
This work will be found eminently fitted for the general practitioner. In cases of functional 
or structural diseases of the eye, the physician who has not made ophthalmic surgery a special 
study can, in most instances, refer v a patient to some competent practitioner. Cases of injury, 
however, supervene suddenly and usually require prompt assistance, and a work devoted espe- 
cially to them cannot but prove essentially useful to those who may at any moment be called upon 
to treat such accidents. The present volume, as the work of a gentleman of large experience, 
may be considered as eminently worthy of confidence for reference in all such emergencies. 

It is an admirable practical book in the highest and best sense of tke phrase.— London Medical Times 
and Gaztttc, May IS, 1867. 



30 



Henry C. Lea's Publications — (Surgery). 



"UTALES {PHILIP S.), M. D., Surgeon U. S. N 



MECHANICAL THERAPEUTICS: a Practical Treatise on Surgical 

Apparatus, Appliances, and Elementary Operations : embracing Minor Surgery, Band- 
aging, Orthopraxy, and the Treatment of Fractures and Dislocations. With six hundred 
and forty-two illustrations on wood. In one large and handsome octavo volume of about 
700 pages: extra cloth, $5 75; leather, $6 75. 
A Naval Medical Board directed to examine and report upon the merits of this volume, officially 
states that " it should in our opinion become a standard work in the hands of every naval sur- 
geon;" and its adoption for use in both the Army and Navy of the United States is sufficient 
guarantee of its adaptation to the needs of every-day practice. 



The title of this book will give a reasonably good 
idea of its scope, but its merits can only be appreci- 
ated by a careful perusal of its text. No one who un- 
dertakes such a task will have any reason to com- 
plain that the author has not performed his duty, and 
has not taken every pains to present every subject in 
a clear, common-sense, and practical light. It is a 
unique specimen of literature in its way, in that, 
treating upon such a variety of subjects, it is as a 
whole so completely up to the wants of the student 
and the general practitioner. We have never seen 
any work of its kind that can compete with it in real 
utility and extensive adaptability. Dr. Wales per- 
fectly understands what may naturally be required 
of him in tbe premises, and in the work before us has 
bridged over a very wide gap which ha ; s always here- 
tofore existed between the first rudiments of surgery 
and practical surgery proper. He has emphatically 
given us a comprehensive work for the beginner ; and 
when we say of his labors, that in their particular 
sphere they leave nothing to be desired, we assert a 
great deal to recommend the book to the attention of 
those specially concerned. In conclusion, we would 
state, at the risk of reiteration, that this is the most 
comprehensive book on the subject that we have seen ; 
is the best that can be placed in the hands of the stu- 



dent in need of a first book on surgery, and the most 
useful that can be named for such general practition- 
ers who, without any special pretensions to surgery, 
are occasionally liable to treat surgical cases. — N. Y. 
Med. Record, March 2, 1S6S. 

It is certainly the most complete and thorough work 
of its kind in the English language. -Students and 
young practitioners of surgery will tind it invaluable. 
It will prove especially useful to inexperienced coun- 
try practitioners, who are continually required to 
take charge of surgical cases, under circumstances 
precluding them from the aid of experienced surgeons. 
— Pacific Med. and Surg. Journal, Feb. 1S68. 

The title of the above work is sufficiently indica- 
tive of its contents. We have not seen for a long 
time (in the English language) a treatise equal to this 
in extent, nor one which is better adapted to the 
wants of the general student and practitioner. It is 
not to the surgeon alone that this book belongs; the 
physician has frequent opportunities to fill an emer- 
gency by such knowledge as is here given. Every 
practitioner should make purchase of such a book- 
it will last him his lifetime. — St. Louis Med. He- 
porter, Feb. 1S68. 



~D1GEL0 W (HENRY J.), M. D., 

•*-* Professor of Surgery in the Massachusetts Med. College. 

ON THE MECHANISM OF DISLOCATION AND FRACTURE 

OF THE HIP. With the Reduction of the Dislocation by the Flexion Method. With 
numerous original illustrations. In one very handsome octavo volume. Cloth. $2 50. 
{Lately Issued.) 

We cannot too highly praise this book as the work graph is largely illustrated with exquisitely executed 

of an accomplished and scientific surgeon. We do woodcuts, after photographs, which help to elucidate 

not hesitate to say that he has done much to clear up the admirable subject-matter of the text. We cop- 

the obscurities connected with the mechanism of dis- dially commend the " Hip," by Dr. Bigelow, to the 

location of the hip-joint, and he has laid down most attention of surgeons. — Dublin Quarterly Journal of 

valuable practical rules for the easy and most sue- Medical Science, Feb. 1S70. 
cessful management of these injuries. The mono- 



THOMPSON (SIR HENRY), 

-*■ Surgeon and Professor of Clinical Surgery to University College Hospital. 

LECTURES ON DISEASES OF THE URINARY ORGANS. With 

illustrations on wood. In one neat octavo volume, extra cloth. $2 25. 
These lectures stand the severe test. They are in- on which Sir Henry Thompson speaks with more au- 



structive without being tedious, and simple without 
being diffuse; and they include many of those prac- 
tical hints so useful for the student, and even more 
valuable to the young practitioner. — Edinburgh Med. 
Journal, April, 1869. 

Very few words of ours are necessary to recommend 
these lectures to the profession. There is no subject 



thority thau that in which he has specially gathered 
his laurels; in addition to this, the conversational 
style of instruction, which is retained in these printed 
lectures, gives them an attractiveness which a sys- 
tematic treatise can never possess. — London Medical 
Times and Gazette, April 24, 186.9. 



B 



Y THE SAME AUTHOR. 



ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 

THE URETHRA AND URINARY FISTULA. With plates and wood-cuts. From the 
third and revised English edition. In one very handsome octavo volume, extra cloth, $# 50. 
( lust Issued.) 

This classical work has so long been recognized as a standard authority on its perplexing sub- 
jects that it should be rendered accessible to the American profession. Having enjoyed the 
advantage of a revision at the hands of the author within a few months, it will be found to present 
his latest views and to be on a level with the most recent advances of surgical science. 

With a work accepted as the authority upon the I ably known'by the profession as this before us, niu?t 
subjects of which it treats, an extended notice would | create a demand for it from those who would keep 
be a work of supererogation. The simple auuouuce- I themselves well up iu this department of surgery.— 
ment of another edition of a work so well a,ad favor- St. Louis Med. Archives, Feb. 1S70. 



Henry C. Lea's Publications — (Medical Jurisprudence, &c). 31 



rPAYLOR {ALFRED S.), M.D., 

•*- Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital. 

MEDICAL JURISPRUDENCE. Sixth American, from the eighth 

and revised London edition. With Notes and References to American Decisions, by Cle- 
ment B. Penrose, of the Philadelphia Bar. In one large octavo volume of 776 pages, 
extra cloth, $4 50 ; leather, $5 50. 



The sixth edition of this popular work comes to as 
in charge of a new editor, Mr. Penrose, of the Phila- 
delphia bar, who has done much to render it useful, 
not only to the medical practitioners of this country, 
but to those of his own profession. Wisely retaining 
the references of the former American editor, Dr. 
Hartshorne, he has added many valuable notes of his 
own. The reputation of Dr. Taylor's work is so well 
established, that it needs no recommendation. He is 
now the highest living authority on all matters con- 
nected with forensic medicine, and every successive 
edition of his valuable work gives fresh assurance to 
his many admirers that he will continue to maintain 
his well-earned position. No one should, in fact, be 
without a text-book on -the subject, as he does not 



know but that his next case may create for him an 
emergency for its use. To those who are not the for- 
tunate possessors of a reliable, readable, interesting, 
and thoroughly practical work upon the subject, we 
would earnestly recommend this, as forming the best 
groundwork for all their future studies of the more 
elaborate treatises. — New York Medical Record, Feb. 
15, 1867. 

The present edition of this valuable manual is a 
great improvement on those which have preceded it. 
It makes thus by far the best guide-book in this de- 
partment of medicine for students and the general 
practitioner in our language. — Boston Med. and Surg. 
Journal, Dec. 27, 1866. 



JDLANDFORD (G. FIELDING), M. D., F. R. C P., 

•*-* Lecturer on Psychological Medicine at the School of St. George's Hospital, &c. 

INSANITY AND ITS TREATMENT: Lectures on the Treatment, 

Medical and Legal, of Insane Patients. In one very handsome octavo volume. {Just 

Ready.) 
In reprinting this work, an Appendix has been added, prepared by Dr. Isaac Ray, embracing 
a summary of the laws of the several States with respect to Certificates of Insanity, and the Con- 
finement of the Insane. 

TyiNSLOW {FORBES), M.D., D. C.L., frc. 

J ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS 

OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- 
phylaxis. Second American, from the third and revised English edition. In one handsome 
octavo volume of nearly 600 pages, extra cloth. $4 25. (Lately Issued.) 
Of the merits of Dr. Winslow's treatise the profes- 
sion has sufficiently judged. It has taken its place in 
the front rank of the works upon the special depart 



ment of practical medicine to which it pertains. — 
Cincinnati Journal of Medicine, March, 1866. 

It is an interesting volume that will amply repay 
for a careful perusal by all intelligent readers. — 
Chicago Med. Examiner, Feb. 1866. 

A work which, like the present, will largely aid 
the practitioner in recognizing and arresting the first 
insidious advances of cerebral and mental disease, is 
ooe of immense pi-actical value, and demands earnest 
attention and diligent study on the part of all who 
have embraced the medical profession, and have 



thereby undertaken responsibilities in which the 
welfare and happiness of individuals and families 
are largely involved. We shall therefore close this 
brief and necessarily very imperfect notice of Dr. 
Winslow's great and classical work by expressing 
our conviction that it is long since so important and 
beautifully written a volume has issued from the 
British medical press.— Dublin Medical Press. 

It is the most interesting as well as valuable book 
that we have seen for a long time. It is truly fasci- 
nating. — Am. Jour. Med. Sciences. 

Dr. Winslow's work will undoubtedly occupy an 
unique position in the medico-psychological litera- 
ture of this country. — London Med. Review. 



T EA {HENRY C.). 

SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF 

LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Second Edition, 
Enlarged. In one handsome volume royal 12mo. of nearly 500 pages; extra cloth, $2 75. 
(Just Issued.) 



The copious collection of facts by which Mr. Lea has 
illustrated his subject shows in the fullest manner the 
constant conflict and varying success, the advances 
and defeats, by which the progress of humane legisla- 
tion has been and is still marked. This work fills up 
with the fullest exemplification and detail the wise 
remarks which we have quoted above. As a book of 
ready reference on the subject it is of the highest 
value. — Westminster Review, Oct. 1S67. 

When — half in spite of himself, as it appears — he 
sketches a scene or character in the history of legalized 
error and cruelty, he betrays so artistic a feeling, and 



a humor so fine and good, that he makes us regret it 
was not within his intent, as it was certainly within 
his power, to render the whole of his thorough work 
more popular in manner. — Atlantic Monthly, Feb. '67. 
This is a book of extraordinary research. Mr. Lea 
has entered into his subject con amove ; and a more 
striking record of the cruel superstitions of our un- 
happy Middle Ages could not possibly have been com- 
piled. . . . As a work of curious inquiry on certain 
outlying points of obsolete law, "Superstition and 
Force"' is one of the most remarkable books we have 
met with. — London At/ienceum, Nov. 3, 1866. 



T>Y THE SAME AUTHOR. (Just Issued.) 

STUDIES IN CHURCH HISTORY— THE RISE OF THE TEM- 
PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large royal 
12mo. volume of 516 pp. extra cloth. $2 75. 
Altogether, the book is a useful addition to the po- 
pular literature of a most important and too little 
known department of mediaeval history. — London 
Saturday Review, Feb. 26, 1870. 

They are careful studies by a thorough scholar in 
the most interesting of all historical fields, made 
without passion or prejudice, aud recorded with hon- 
esty. The whole volume is of the deepest interest ; 
the style is masculine and animated, and great skill 



is shown in weaving in anecdote and picturesque 
stories, without impairing the flow of the relation or 
the proper dignity of the composition.— Hartford 
Courant, Jan. 22, 1S70. 

We recommend the book as a highly instructive 
discussion of matters which are always of interest to 
scholars, and which are just nowclothed with a spe- 
cial importance.— JV r . Y. Nation, Feb. 3, 1870. 



32 



Henry C. Lea's Publications. 



INDEX TO CATALOGUE 



Allen's Dissector and Practical Anatomist 
American Journal of the Medical Sciences 
Abstract, Half-Yearly, of the Med. Sciences 
Anatomical Atlas, by Smith and Horner 
Ashton on the Rectum and Anus . 
Attfield's Chemistry .... 
Ashwell on Diseases of Females . 
Ashhurst's Surgery .... 

Barnes on Diseases of Women 
Bryant's Practical Surgery . 
Blandford on Insanity .... 
Basham on Renal Diseases . 
Brinton on the Stomach 
Bigelow on the Hip .... 

Barclay s Medical Diagnosis . 
Barlow's Practice of Medicine 
Bowman's (John E.) Practical Chemistry 
Bowman's (John E.) Medical Chemistry 
Brande & Taylor's Chemistry 
Brodie's Clinical Lectures on Surgery . 
Buckler on Bronchitis .... 
Bucknill and Tuke on Insanity 
Bumstead on Venereal .... 
Bumstead and Cullerier's Atlas of Venereal 
Carpenter's Human Physiology . 
Carpenter's Comparative Physiology . 
Carpenter on the Use and Abuse of Alcohol 
Carson's Synopsis of Materia Medica . 
Chambers on the Indigestions 
Christison and Griffith's Dispensatory 
Churchill's System of Midwifery . 
Churchill on Puerperal Fever 
Condie on Diseases of Children . 
Cooper's (B. B.) Lectures on Surgery . 
Cullerier's Atlas of Venereal Diseases 
Cyclopedia of Practical Medicine . 
Dalton's Human Physiology . 
De Jongh on Cod-Liver Oil .... 
De wees' s System of Midwifery 
Dewees on Diseases of Females . 
Dewees on Diseases of Children . 
Dickson's Practice of Medicine 
Druitt's Modern Surgery 
Dunglison's Medical Dictionary . 
Dunglison's Human Physiology . 
Dunglison on New Remedies 
Ellis's Medical Formulary, by Smith . 
Erichsen's System of Surgery 
Erichsen on Nervous Injuries 
Flint on Respiratory Organs . 

Flint on the Heart 

Flint's Practice of Medicine . 
Fownes's Elementary Chemistry . 
Fuller on the Lungs, &c. 

Gibson's Surgery 

Gluge's Pathological Histology, by Leidy 
Graham's Elements of Chemistry . 

Gray's Anatomy 

Griffith's (R. E.) Universal Formulary 
Gross on Foreign Bodies in Air-Passages 
Gross's Principles and Practice of Surgery 
Gross's Pathological Anatomy 
Guersant on Surgical Diseases of Children 
Hartsl|orne's Essentials of Medicine . 
Hartshorne's Conspectus of the Medical Sciences 
Hartshorne's Anatomy and Physiology 
Hamilton on Dislocations and Fractures 
Harrison on the Nervous System . 
Heath's Practical Anatomy . 
Hoblyn's Medical Dictionary 

Hodge on Women 

Hodge's Obstetrics 

Hodge's Practical Dissections 
Holland's Medical Notes and Reflections 
Horner's Anatomy and Histology 
Hudson on Fevers, .... 

Hill on Venereal Diseases 
Hillier's Handbook of Skin Diseases 
Jones and Sieveking's Pathological Anatomy 
Jones (C. Handfield) on Nervous Disorders 
Kirkes' Physiology ..... 



PAGE 

. 6 
. 1 
. 3 



Scie 



abridged 



Knapp's Chemical Technology . 

Lea's Superstition and Force . 

Lea's Studies in Church History . 

Lallemand and Wilson on Spermatorrhoea 

La Roche on Yellow Fever . 

La Roche on Pneumonia, &c. 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye .... 

Laycock on Medical Observation . 

Lehmann's Physiological Chemistry, 2 vols 

Lehmann's Chemical Physiology . 

Ludlow's Manual of Examinations 

Lyons on Fever ..... 

Maclise's Surgical Anatomy . 

Marshall's Physiology .... 

Mackenzie on Diseases of the Eye 

Medical News and Library . 

Meigs's Obstetrics, the Science and the Art 

Meigs's Lectures on Diseases of Women 

Meigs on Puerperal Fever 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Montgomery on Pregnancy . 

Morland on Urinary Organs . 

Morland on Uraemia 

Neill and Smith's Compendium of Med 

Neligan's Atlas of Diseases of the Skin 

Neligan on Diseases of the Skin 

Odling's Practical Chemistry 

Pavy on Digestion 

Prize Essays on Consumption 

Parrish's Practical Pharmacy 

Pirrie's System of Surgery . 

Pereira's Mat. Medica and Therapeutics, 

Quain and Sharpey's Anatomy, by Leidy 

Ranking's Abstract 

Radcliff aad others on the Nerves, &c 

Roberts on Urinary Diseases . 

Ramsbotham on Parturition . 

Rigby on Female Diseases 

Rigby's Midwifery .... 

Rokitansky's Pathological Anatomy 

Royle's Materia Medica and Therapeut 

Salter on Asthma . 

Swayne's Obstetric Aphorisms 

Sargent's Minor Surgery 

Sharpey and Quain's Anatomy, by Leidy 

Simou's General Pathology . 
Simpson on Females 

Skey's Operative Surgery 
Slade on Diphtheria 

Smith (J.L.)on Children 
Smith (H. H.) and Horner's Anatomical Atlas 
Smith (Edward) on Consumption . 
Smith on Wasting Diseases of Children 
Solly on Anatomy and Diseases of the Brai 
Stillg's Therapeutics .... 
Tanner's Manual of Clinical Medicine . 
Tanner on Pregnancy .... 
Taylor's Medical Jurisprudence . 
Thomas on Diseases of Females . 
Thompson on Urinary Organs 
Thomp-on on Stricture .... 
Todd and Bowman's Physiological Anatomy 
Todd on Acute Diseases .... 
Toynbee on the Ear .... 
Wales on Surgical Operations 
Walshe on the Heart .... 
Watson's Practice of Physic . 

Wells on the Eye 

West on Diseases of Females 
West on Diseases of Children 
West on Ulceration of Os Uteri 
What to Observe in Medical Cases 
Williams's Principles of Medicine 
Wilson's Human Anatomy . 
Wilsou on Diseases of the Skin . 
Wilson's Plates on Diseases of the Skin 
Wilson's Handbook of Cutaneous Medicine 
Wilson on Spermatorrhoea . . 
Winslow on Brain and Mind 



Paob 
10 



INSANITY AND ITS TREATMENT. 



LECTURE I. 

Introductory — Impossibility of avoiding Insanity — Why the Study of 
Insanity is a Branch of Medicine — The Organ of Mind — The Nerve 
Centres and Cells — The Nerve Fibres — Their Distribution — The 
Blood Supply of the Brain — Nerve Function — Method of Study Two- 
fold. 

Gentlemen, — If there be one branch of the great study of 
medicine which more than another deserves to be called an 
art and a mystery, it is the treatment and investigation of 
insanity. The treatment is an art, which, during the pres- 
ent century, has advanced in a degree not inferior to other 
arts, and in which by practice and example w r e may hope to 
attain skill, as in surgery or midwifery ; but the disorder 
which we call insanity is a mystery not yet unravelled. Can 
we even define it? 

" To define true madness, 
What is't but to be nothing else than mad ?" 

In truth, its inscrutable appearance without assignable cause 
in a man hitherto sane, and its no less inscrutable departure, 
are things which w r e must confess are not yet explicable by 
human knowledge. Nevertheless, it is a branch of our art 
which is constantly forcing itself upon our attention. There 
are diseases described in the lectures you here attend which 
throughout your lives may never come before }■ ou : you may 
never see a patient die of hydrophobia: you may be so- 



18 OF THE ORGANS OF MIND. 

blessed with a healthy locality that you may never have to 
treat Asiatic cholera or ague. And other ailments due to 
locality or to special occupations you may never witness. 
But fortunate indeed will you be, if you spend many years 
in practice without being called upon to treat or to 

Impossibility . . 

of avoiding pronounce an opinion upon, some case of unsound- 
msamty. negg ^ mind. Your female patients after parturi- 
tion will be attacked with insanity; their boys and girls as 
they come to the age of puberty will show symptoms of it; 
at the climacteric of life men and women will break down ; 
and in old age insanity will merge into fatuity and dotage 
in the general decay of mind and body. From the cradle to 
the grave the mental no less than the bodily health of your 
patients must be your care. And not only will you have to 
treat them, you will have to send them away from home 
under legal restraint, to plead their irresponsibility in courts 
of law, if in their frenzy or folly they commit crime ; and 
when they are dead, you will be called on to testify to 
their competency or incompetency to make the w r ill they 
have left behind. 

Now, if your attention has been drawn to insanity chiefly 
by notices of the grave disputes that arise in courts of law 
both upon the subject in general and also upon the sanity or 
insanity of individuals, you may shrink from the prospect I 
have set forth, and may determine to have nothing to do with 
such cases. You may resolve, like others I have known, 
never to sign a certificate. You may possibly carry out your 
resolution in London, but in the country }^ou can no more 
escape from this duty than from other branches of our pro- 
fession, which here we may hand over to specialists; and an 
opinion you may have to give on the state of mind of any of 
your patients ; therefore it behooves you to have some idea 
of what you may have to say on the subject, as well as of 
the treatment of the various kinds of insane patients. In my 
lectures I shall endeavor to direct your attention to both of 



OF THE ORGANS OF MIND. 19 

these points, that you may be able to refer to them as notes 
for future guidance in your medical, and also your medico- 
legal capacity. About the mysterious psychological part of 
the question, I shall only say so much as will enable you to 
understand various doctrines and theories which have been 
put forth, and which may be propounded in opposition to 
your own by others, whether lawyers or doctors. You will 
be asked if you agree or disagree with the theory of Dr. A. 
concerning "moral insanity," or of Dr. B. as to "emotional 
insanity," or of Dr. C. as to " volitional insanity." You will 
be told that delusions are essential to constitute a man legally 
insane, that insane people are responsible if they know right 
from wrong. Some amount of information fis to mind in gen- 
eral is therefore necessary : this I shall try to make as brief 
as possible, in which I may succeed ; and as little obscure as 
I can, in which my success may be less. 

We will suppose that you have for the first time walked 
through the wards and inspected the patients in a lunatic 
asylum, sufficiently populous to have given you the oppor- 
tunity of seeing all or nearly all the phases of this malady. 
You have seen some whose appearance, acts and language 
showed at once that something was wrong with them, others 
whose manner betrayed nothing, but whose conversation im- 
mediately indicated that they w r ere not like men in general : 
some, on the contrary, appeared rational both in conduct 
and conversation, while in a considerable number you no- 
ticed a negative, not a positive alienation, an absence of 
word and thought, of work or amusement, a mental blank. 
You have not, however, gained much insight into the one 
thing, insanity, which you came to look for. You have 
failed to recognize one disorder from which all are suffering; 
'to see how it is that these, who one and all are secluded 
in this abode, differ from the rest of mankind on the other 
side of the wall. Why they are here, and how they are to 
be cured so as to re-enter the world, is what I wish to show. 



20 OF THE ORGANS OF MIND. 

r 

But a great number never will be cured ; they must be 
taken care of for the rest of their lives. The curability and 
incurability I shall point out, but into the details of the care 
and treatment of such incurable patients I shall not entej\ 

If you ask me in what particular the inmates of the asy- 
lum agree, I can only say that they are all persons of un- 
sound mind. Some are congenital idiots; some are epileptic 
patients, whose minds, memory, and understanding have 
been destroyed by frequent fits; some have had paralytic 
strokes with a similar result; some are in the dotage of age; 
others are insane in the common meaning of the word, hold- 
ing extraordinary opinions and doing outrageous acts, and 
incarcerated here because they cannot be taken care of in 
any other way, or because their chance of recovery is in- 
creased by the restraint and treatment they receive. They 
resemble one another only in this, that they are all of un- 
sound mind, incapable of taking care of themselves or of 
managing their affairs. This you see is a mere legal or civil 
distinction, yet it is one we cannot overlook, for it is the link 
which binds them all together. On analyzing them, we find 
that in antecedents and history, in capacity, in peculiarities, 
in propensities, they are of infinite variety: no two are alike, 
yet all are confined here nohntes volentes, and are here upon 
the certificates of medical men. What then, }^ou ask, is 
Tiru t meant by this legal term, unsoundness of mind ? in 

Why the J ° 7 

study of in- what way does it become a branch of medical study 

sanity is a .. • o l l i • i • r»i 

branch of and practice I by what application 01 the art and 
science of medicine is it to be removed ? 
The answer is, that unsoundness of mind is but another 
term for disorder of the human brain, or rather of that por- 
tion of nerve matter which has for its function that which 
we call mind and mental operation. For all that is con* 
tained within the cranium is not concerned with the opera- 
tions of mind proper, but a portion only, so that the function 
of certain parts may be disordered, the mind remaining 



OF THE ORGANS OF MIND. 21 

sound; and, conversely, the mind may be deranged and 
defective, while other nerve functions, as the senses, continue 
intact. The proper function of the mental portion of the 
brain is, moreover, not essential to existence, and patients 
may live in a state of unsound mind during the whole term 
of a natural life. 

It is not within the province of my lectures to discuss the 
functions of the various parts of that which, as a whole, we 
call the brain. From your lecturer on physiology you will 
already have learned what is known about them, and will 
have heard that great doubt exists even now as to the duties 
which they discharge, and their relations one to another. 
I shall only mention such points with regard to them as are 
essential to my purpose ; but it is to be remembered that 
there is within the cavity of the cranium a number of organs 
capable, more or less, of acting independently of each other, 
and more or less developed in different animals. These all 
agree, however, in certain particulars : all are compounded 
of nerve cells, having certain special properties, and con- 
nected with one another by means of nerve fibres, bundles 
of which conduct to other cell-groups or to the periphery. 
These groups of cells, which I shall call nerve centres, are sup- 
plied by bloodvessels, and on the supply depends mainly the 
proper performance of their special function. If this be in- 
adequate or ill-regulated, or if the blood itself be impure, the 
function shows an equal disturbance. Here, then we have 
four things to consider, the nerve centres, the nerve fibres, 
the supply of blood, and the function or property of the cen- 
tres. These can be studied to some extent by experiment, 
as well as observed in health and disease. In this manner 
much has been learned by various experimental physiolo- 
gists which can be advantageously applied to the consid- 
eration of the physiology and pathology of the special 
centres of human mind, the two great hemispheres of the 
cerebrum. 



22 OF THE ORGANS OF MIND. 

The nerve centres are aggregates of nerve cells which are 
imbedded in a substance or stroma called the " neu- 

The nerve 

centres and roglia," which in the brain appears to be a "trans- 
parent, nucleated, homogeneous, non-fibrillated ma- 
trix, representing the fibrillated connective tissue of the 
spinal cord." 1 Of this as yet little is known, but I believe 
that it will be found to play an important part in the pa- 
thology, if not as an immediate agent, of mind. 

These cells or vesicles consist of a very fine membrane, 
containing granular matter of various colors. They differ 
in shape, being round, pyriform, stellate, irregular, and also 
in size, ranging in man from the T2 ^th to the -g^th of an 
inch in diameter. From cell to cell proceed the nerve fibres 
connecting them with each other and with other parts. Mr. 
Lockhart Clark has given us a description of the way in 
which these cells are arranged in the human brain, which I 
can do no less than describe verbatim. It was contributed 
by him to the second edition of Dr. Maudsley's work on the 
Physiology and Pathology of Mind. " In the human brain 
most of the convolutions, when properly examined, may 
be seen to consist of at least seven distinct and concen- 
tric layers of nervous substance, which are alternately paler 
and darker from the circumference to the centre. The lam- 
inated structure is most strongly marked at the extremity of 
the posterior lobe. In this situation all the nerve cells are 
small but differ considerably in shape, and are much more 
abundant in some layers than in others. In the superficial 
layer, which is pale, they are round, oval, fusiform, and 
angular, but not numerous. The second and darker layer is 
densely crowded with cells of a similar kind, in company 
with others that are pyriform and pyramidal, and lie with 
their tapering ends either towards the surface or parallel 
with it, in connection with fibres which run in corresponding 

1 Drs. Tuke and Rutherford on Morbid Appearances in the Brains of the Insane, 
"Edinburgh Medical Journal," Oct. 1869. 



OF THE ORGANS OF MIND. 23 

directions. The broader ends of the pyramidal cells give off 
two, three, four or more processes, which run partly towards 
the central white axis of the convolution, and in part hori- 
zontally along the plane of the layer, to be continuous, 
like those at the opposite ends of the cells, with nerve fibres 
running in different directions. 

" The third layer is of a much paler color. It is crossed, 
however, at right angles by narrow and elongated groups of 
small cells and nuclei of the same general appearance as 
those of the preceding layer. These groups are separated 
from each other by bundles of fibres radiating towards the 
surface from the central white axis of the convolution, and 
together with them form a beautiful fan-like structure. 

" The fourth layer also contains elongated groups of small 
cells and nuclei, radiating at right angles to its plane, but 
the groups are broader, more regular, and, together with the 
bundles of fibres between them, present a more distinctly 
fan-like arrangement. 

" The fifth layer is again paler and somewhat white. It 
contains, however, cells and nuclei which have a general 
resemblance to those of the preceding layers, but they ex- 
hibit only a faintly radiating arrangement. 

" The sixth and most internal layer is reddish gray. It 
not only abounds with cells like those already described, 
but contains others that are rather larger. It is only here 
and there that the cells are collected into elongated groups, 
which give the appearance of radiations. On its under side 
it gradually blends with the central white axis of the convo- 
lution, into which its cells are scattered for some distance. 

" The seventh layer is this central white stem or axis of 
the convolution. On every side it gives off bundles of fibres, 
which diverge in all directions, and in a fan-like manner, 
towards the surface through the several gray layers. As 
they pass between the elongated and radiating groups of 
cells in the inner gray layers, some of them become continu- 



24 OF THE ORGANS OF MIND 

ous with the processes of the cells in the same section or 
plane, but others bend round and run horizontally, both in 
a transverse and longitudinal direction (in reference to the 
course of the entire convolution), and with various degrees of 
obliquity. While the bundles themselves are by this means 
reduced in size, their component fibres become finer in pro- 
portion as they traverse the layers towards the surface, in 
consequence, apparently, of branches which they give off to 
be connected with cells in their course. Those which reach 
the outer gray layer are reduced to the finest demensions, 
and form a close network, with which the nuclei and cells 
are in connection. 

" Besides these fibres, which diverge from the central 
white axis of the convolution, another set, springing from the 
same source, converge, or rather curve inwards from oppo- 
site sides to form arches along some of the gray layers. 
These archiform fibres run in different planes — transversely, 
obliquely, and longitudinally — and appear to be partly con- 
tinuous with those of the diverging set which bend round, 
as already stated, to follow a similar course. All these 
fibres establish an infinite number of communications in 
every direction between different parts of each convolution, 
between different convolutions, and between these and the 
central white substance. 

"The other convolutions of the central hemispheres differ 
from those at the extremities of the posterior lobes, not 
only by the comparative faintness of their several layers, 
but also by the appearance of some of their cells. We have 
already seen that at the extremity of the posterior lobe the 
cells of oil the layers are small, and of nearly uniform size, 
the inner layer only containing some that are a little larger. 
But on proceeding forward from this point, the convolutions 
are found to contain a number of cells of a much larger kind. 
A section, for instance, taken from a convolution at the ver- 
tex, contains a number of large, triangular, oval, and pyra- 



OF THE ORGANS OF MIND. 25 

midal cells, scattered at various intervals through the two 
inner bands of archiform fibres and the gray layer between 
them, in company with a multitude of smaller cells, which 
differ but little from those at the extremity of the posterior 
lobe. The pyramidal cells are very peculiar. Their bases 
are quadrangular, directed towards the central white sub- 
stance, and each gives off four or more processes, which run 
partly towards the centre, to be continuous with fibres ra- 
diating from the central white axis, and partly parallel with 
the surface of the convolution, to be continuous with archi- 
form fibres. The processes frequently subdivide into minute 
branches, which form part of the network between them. 
The opposite end of the cell tapers gradually into a straight 
process, which runs directly towards the surface of the con- 
volution, and may be traced to a surprising distance, giving 
off minute brandies in its course, and becoming lost, like the 
others, in the surrounding network. Many of these cells, as 
well as others of a triangular, oval, and pyriform shape, are 
as large as those in the anterior gray substance of the spinal 
cord. 

" In other convolutions the vesicular structure is again 
somewhat modified. Thus, in the surface convolution of 
the great longitudinal fissure, on a level with the anterior 
extremity of the corpus callosum, and, therefore, correspond- 
ing to what is called the superior frontal convolution, all the 
three inner layers of gray substance are thronged with py- 
ramidal, triangular, and oval cells of considerable size, and 
in much greater number than in the situation last mentioned. 
Between these, as usual, is a multitude of nuclei and smaller 
cells. The inner orbital convolution, situated on the outer 
side of the olfactory bulb, contains a vast multitude of pyri- 
form, pyramidal, and triangular cells, arranged in very 
regular order, but none that are so large as many of those 
found in the convolutions of the vertex. Again in the insula, 
or island of Rett, which overlies the extra-ventricular por- 



26 OF THE ORGANS OF MIND. 

tion of the corpus striatum, a great number of the cells are 
somewhat larger, and the general aspect of the tissue is 
rather different. A further variety is presented by the tem- 
poro-sphencidal lobe, which covers the insula, and is continu- 
ous with it; for, while in the superficial and deep layers the 
cells are rather small, the middle layer is crowded with py- 
ramidal and oval cells of considerable and rather uniform 
size. But not only in different convolutions does the struc- 
ture assume to a greater or less extent a variety of modifica- 
tions, but even different parts of the same, convolution may 
vary with regard either to the arrangement or the relative 
size of their cells. 

"Between the cells of the convolutions in man and those 
of the ape tribe I could not perceive any difference whatever; 
but they certainly differ in some respects from those of the 
larger mammalia — from those, for instance, of the ox, sheep, 
or cat." 

The nerve fibres, or nerve tubes, as they are often called, 
The nerve which conduct to and from the nerve centres, also vary 
fibres. j n s * ze f rom t ne millionth to the n 1 M th of an inch 
in diameter. They form the white or commissural substance 
of the nervous system, being gathered into fasciculi, compris- 
ing a large number of these fibres. Each fibre consists of a 
very delicate membrane, forming a tube, and containing a 
viscid, albuminous and fatty pulp. Inclosed in this tube is 
a minute fibre, or "axis cylinder," which is in truth the real 
nerve fibre, and which exists in places without its investing 
sheath. At the peripheral extremity it parts w r ith the latter, 
and is divided and subdivided as it permeates and blends 
with the structure in which it is distributed, while at the 
other end it becomes continuous with the contents of the 
nerve cells, also parting with its sheath at this point. That 
the nerve fibre is protected from disturbance by the invest- 
ing sheath and pulp there can be no doubt, and that the 
latter plays a part in the preservation of the healthy work- 



OF THE ORGANS OF MIND. 27 

ing of the whole system seems probable from the changes 
observable in it in certain diseases. You will not forget that 
a nerve fibre possesses a power of its own, even when severed 
from its connection with a nerve centre, and that this power, 
if exhausted by stimulation, may by rest be again recovered; 
and it apears to me likely that the nerve elements surround- 
ing the fibre may contribute materially to the restoration of 
this power. 

The white or commissural portion of the brain deserves 
attention no less than the gray matter or centres, because by 
it the latter are brought into relation one with another. 
You have probably heard elsewhere of the hemispheres of 
the brain, of their convolutions, and of their function, of the 
sensory ganglia and their function, and of the relations of 
the one to the other. You have heard of sensori-motor acts, 
and the independence of the sensory ganglia. You will see 
it stated that in the corpora striata and optic thalami end 
all the fibres coming from below, and that in consequence 
all external stimuli are transmitted indirectly through the 
sensory ganglia to the hemispheres, while in turn they are 
the starting-point of all motor impulses which come from the 
cerebrum. Flourens, Hertwig, Magendie, Lon get, SchifF, and 
others, have removed the cerebral hemispheres in mammals, 
birds, and reptiles, and observed what could be done by 
creatures in this condition. A pigeon followed a lighted 
candle with a corresponding movement of the head, and 
sought out the light part of a darkened room. If a pistol 
was fired close to it, it raised its head, opened its eyes, 
stretched out its neck, and then relapsed into a state of sleep. 
But though such animals indicate that they possess the senses 
of seeing and hearing, they appear destitute of memory or 
judgment. They are not frightened at the cry of birds of 
prey. They cannot regulate their movements so as to avoid 
an obstacle, but unwittingly dash against it. They have not 
lost hearing or sight, but are deprived of ideation and intel- 



28 OF THE ORGANS OF MIND. 

ligence. " The condition of such beings," says Dr. Carpenter, 1 
"seems to resemble that of a man who is in a slumber suffi- 
ciently deep to lose all perception of objects, but who is con- 
scious of sensations, as appears from the movements occa- 
sioned by light or by sounds, or from those which he executes 
to withdraw the body from an uneasy position." These 
experiments prove that the cerebral hemispheres are not 
necessary to the life of such creatures, nor to the existence of 
the senses ; but interesting as they are, they teach us little 
of the anatomy or physiology of the brain of man. The 
functions of the various ganglia situated below the hemi- 
spheres of our own brain are not as yet made out with any- 
thing like certainty. But one important step will be gained 
when we accurately ascertain the commissural connections of 
the various ganglia below the hemispheres, and the various 
convolutions of the latter. Dr. Broadbent has communicated 
to the Boyal Society an account of certain dissections made 
by him, which are of the greatest importance to those who 
are studying the functions of the various parts of the brain. 
Distribution He has found that the fibres ascending in the crus 
of the fibres. cere b r i d no t a ll pass to and terminate in the central 
ganglia, but that a portion passes by the latter, while others 
pass through them to the convolutions. In their passage 
through the ganglia, they are reinforced by numerous fibres, 
arising both in the corpus striatum and thalamus, but mainly 
in the latter. It would appear that many fibres of the crus 
end in the gray matter of the corpus striatum, but apparently 
not in the thalamus. Till this is definitely settled, no con- 
clusions can be drawn as to the function of the thalamus and 
corpus striatum. It will also be necessary to determine 
whence come the fibres which do terminate in the corpus 
striatum. " In the distribution to the convolutions of the 
fibres which emerge from the cerebri mass, they are for the 

1 Human Physiology, 6th edition, p. 546. 



OF THE ORGANS OF MIND. 29 

most part intermingled, and pass to the same regions. Those 
of the crust and tegrnent (the two portions of the crus cerebri) 
are so mixed up as to be quite indistinguishable; in the fronto- 
parietal part of the hemisphere, those of the thalamus pass 
with and cannot be distinguished from those of the crus, 
while the fibres of the corpus striatum, though following an 
independent course, reach the same destination. Again, in 
the occipital lobe the fibres of the crus and ganglia, which 
here are not mingled together, run to the same convolutions, 
and in the temporo-sphenoidal lobe the thalamus and corpus 
striatum give fibres to the same parts. Anatomical struc- 
ture does not, therefore, lead us to expect that there will be 
a distinct sensory and motor region of convolutions. It is 
very remarkable, again, that the fibres of the corpus callosum 
are distributed to the same parts of the surface gray matter 
as the fibres issuing from the centres. Assuming that the 
corpus callosum is not only the transverse commissure of the 
two hemispheres, but that the fibres in it connect correspond- 
ing parts (as can be demonstrated with regard to some parts 
of this commissure), this would imply that the points of the 
surface gray matter of the two hemispheres in which the 
central fibres ended were bilaterally associated. 

" It has further been found, that throughout the hemisphere 
the distribution of the central and callosal fibres is to the 
margin of the respective lobes, leaving extensive intermediate 
tracts of convolutions, which receive no fibres from either crus, 
central ganglia, or corpus callosum. It is at once obvious that 
these superadded convolutions will be the convolutions most 
characteristic of the human brain, and will constitute the dif- 
ference between one brain and another. This is seen if we 
compare the brain of a monkey with that of man. The sen- 
sations transmitted upwards from the several sense centres 
must first impinge upon those parts of the surface gray mat- 
ter in which the fibres from the sensory tract or ganglia end; 
so again, wherever volitions may be originated, the downward 



30 OF THE ORGANS OF MIND. 

starting-point of the motor impulse must be in some convolu- 
tions connected by fibres with the motor ganglion or tract. 
These convolutions, then, which receive central fibres, and 
are bilaterally associated by the corpus callosum, will consti- 
tute perceptive centres, and centres for the emission of voli- 
tional or ideo-motor impulses. But the perception of sensa- 
tions and the emission of motor impulses are psychical 
operations of the simplest character, and are common to man 
and the lower animals. The higher and more complex ope- 
rations of combining and comparing perceptions, the forma- 
tion and elaboration of ideas, are thus almost by way of ex- 
clusion assigned to the superadded convolutions; and it can 
scarcely be considered fanciful to see in the withdrawal of the 
nerve cells engaged in these intellectual operations from im- 
mediate relation with the external world, and in the intricate 
associations of different parts of the surface, conditions adapted 
to the function attributed to them." 1 

I shall not wait to discuss the probable changes which take 
place in the nerve tubes or nerve centres as they are stimu- 
lated into sensation, and as this results in motion. The most 
abstruse questions of chemistry and physics are here involved, 
questions which verge on the metaphysical, and, if discussed 
at all, must be discussed at length. The cells of the nervous 
system must be looked upon chemically as the most prone to 
decomposition and recomposition, perhaps, of all the struc- 
tures of our body. That these changes are set up in them 
by the motion or change conducted thither by the nerve 
fibres, and that decomposition results in other changes pro- 
duced in the efferent fibres, and thus carried to other centres 
of the muscular system, we may accept as a fact. But the 
chemistry and the physics of the brain are not yet sufficiently 
investigated for me to say anything about them. Much has 
been written and said concerning the electrical condition of 
nerve, but for this I must refer you to the writings of those 

1 Journal of Mental Science, April, 1870. 



OF THE ORGANS OF MIND. 31 

who have made it their study. Their opinions on the sub- 
ject vary widely, and into an examination of them I cannot 
enter here. 

The next point we have to consider is the blood supply of 
the brain ; and this is of so great importance, that if we blood 
could comprehend it beyond all manner of dispute, supply of 
we should go far towards explaining most of the phe- 
nomena of brain function and disorder. One might, in truth, 
write a volume in discussing the brain circulation, as has been 
done ere now, and the most that I can do within the limits 
of a lecture is to direct your attention to some of the most 
striking facts connected with it. 

The arterial system, whether in its trunks, branches, or 
capillaries, is peculiar; not less so is the venous. The arte- 
ries supplying the entire encephalon are four in number, — 
the two internal carotids and the two vertebrals coming; from 
the subclavian and uniting to form the single basilar. Now, 
if you look at the arrangement of these arteries within the 
cranium, }'ou will see that the encephalon is not supplied 
with blood, as the kidney, or the liver, or the spleen, by 
means of a large artery entering the substance of the organ, 
and subdividing into smaller ones; but, on the contrary, all 
the larger vessels are arranged on the outside, and only their 
fine prolongations enter it. And in the case of the cerebral 
hemispheres, which are the parts with which we are chiefly 
concerned, we find that the blood is conveyed to the gray 
matter entirely from the outside, by means of very minute 
vessels dipping into it from the branches ramifying in the pia 
mater. 

Most of these arteries have great facilities for rapid con- 
traction and dilatation after they have once passed through 
the bony canals by which they enter the cranium. The in- 
ternal carotids pass through the cavernous sinus, and are pro- 
tected from pressure by the blood there ; and then, like the 
vertebrals and basilar, they are surrounded by the subarach- 



32 OF TIIE ORGANS OF MIND. 

noid fluid at the base of the brain, and the vessels in the pia 
mater have facilities for contraction and dilatation which 
they could not have were they imbedded in the interior of 
the organ. 

I need not here describe the course of these arteries within 
the cranium — how the tw T o vertebral join to form the basilar, 
and afterwards divide into the posterior cerebral ; how these 
are connected by means of the posterior-communicating with 
the internal carotids, which are, themselves, connected by 
the anterior-communicating, forming in this manner the 
so-called circle of Willis. We are not to suppose that this 
"circle " implies a circulation, or that under ordinary circum- 
stances there is any admixture of the blood coming from these 
various sources. The posterior-communicating arteries are 
the merest twigs, and in the rapid and constant contraction 
and dilatation of the cerebral vessels their function must or- 
dinarily be nil; consequently we may practically affirm that 
the whole posterior portion of the encephalon is supplied by 
the vertebrals, viz., the posterior cerebral lobes, the back part 
of the corpus callosum, the fornix, optic thalami, corpora 
quadrigemina, pons, cerebellum, and medulla oblongata. 

We find, then, the anterior brain supplied by the carotids, 
viz., the anterior and middle lobes, the anterior and greater 
portion of the corpus callosum, the corpora striata, the olfac- 
tory lobes, and the front part of the optic tract. That free 
anastomosis does not exist between the vessels supplying 
these parts and those of the vertebrals, and even between the 
tw r o carotid arteries, is proved by the results of many an op- 
eration upon the carotid. That compression of the carotids 
in man produces stupor and collapse was known before the 
time of Galen, and during this century it has been proposed 
as a remedial measure. Tying the common carotid on one 
side is generally followed by some amount of cerebral symp- 
toms, and is occasionally the cause of paralysis and shrinking 
of one hemisphere, showing that even the comparatively large 



OF THE ORGANS OF MIND. 33 

anterior-communicating artery is not sufficient in all cases to 
provide a due supply. You know, of course, that after deli- 
gation of an important vessel in other parts of the body, some 
time must elapse before the collateral circulation is established, 
and the patient is in danger till this happens. But there is 
greater danger to the brain than to structures less highly or- 
ganized, and an interruption of brain function may occur 
when one or other of these arterial streams is checked, not 
stopped, by causes other than deligation. 

Now the contraction and dilatation of arteries are under 
the control of what we call the vaso-motor system of nerves, 
that system which is now so greatly attracting the attention 
of physiologists, about which, however, there are so many 
doubts and difficulties. The trunks and branches within the 
cranium are largely supplied with vaso-motor nerves, which 
may be seen running along them so far as the pia-mater. In 
the gray cerebral substance, the smaller branches and capil- 
laries are without nerves, and so it needs must be that the 
contraction and dilatation of these vessels must depend on 
that of others, and on causes external to the gray substance. 
It depends, in fact, upon the influence of the vaso-motor 
nerves, which influence is derived from the special nerve- 
centre whence they emanate. And tracing them back to this, 
we find that those which accompany the internal carotid and 
its branches are derived from the first great cervical ganglion 
of the sympathetic; those which belong to the vertebrobasilar 
system come from the second and third cervical ganglia: con- 
sequently the two systems of vessels are still further kept 
distinct by their nervous supply. 

All these considerations assist us in our endeavors to 
form some ideas as to the functions of various parts of the 
encephalon. They confirm the probability of various vascu- 
lar areas, as Dr. Hughlings Jackson suggests. They indi- 
cate how MM. Prevost and Cotarcl's experiments on animals 
produced their effects. These gentlemen injected extremely 

3 



d4 OF THE ORGANS OF MIND. 

fine seeds into the carotids of animals, which, being carried 
into the brain substance, caused softening, showing that no 
anastomosis came to the rescue. They assist us, moreover, 
in understanding many of the phenomena of sleep, dreams, 
and somnambulism, and these it is incumbent on every stu- 
dent of insanity closely to watch and analyze. 

Passing from the consideration of these various organs, the 
Nerve nerve centres, the connecting fibres, # and the blooclves- 
function. ge ] s w hi cn supply them with life, we have next to in- 
quire into this life, into their uses and properties, into what is 
commonly called their function. We must ascertain if there 
be any functions common to all of them, or, where they differ, 
in what respect they differ, and what their relations are one 
to another. By such researches we shall be better able to 
understand how these functions may be disturbed and altered; 
in other words, what is the pathology of the nervous system. 

If we go down to the lowest forms of life, we shall find 
that nerve force or function is in itself a specialization of 
something lower, which we must call vital force. We have 
no other name for it. We see animals leading lives and 
manifesting the phenomena of sensibility and motion, in 
whom we can discover no nervous system at all ; and as we 
ascend the scale, at first the same organs appear to subserve 
many purposes, and only at last do we find special organs 
for special functions. Nay, it is even yet a question whether 
in man the sensory and motor nerves may not occasionally 
interchange functions, and motor nerves become sensory, and 
sensory, motor. 1 

The method by which we approach the study of nerve 
function is twofold. On the one hand, it may be 

Method of . . , -, • i i ■ 

study two- contemplated as it is exhibited by all beings, — men, 

children, lunatics, idiots, animals of every grade ; on 

the other, we may examine ourselves. The former is called 

1 Carpenter's Physiology, 6th edition, p. 451. 



OF THE ORGANS OF MIND. 35 

the objective, the latter the subjective mode of inquiry. By 
the first is revealed to us the nature of the nerve functions 
of other men and animals, as derived from the operations 
thereof, from the movements, acts, and speech. By the other 
is to be studied our own feeling and our own consciousness, 
that knowledge of ourselves and what goes on within us, 
which to some has appeared the only true knowledge, and 
the only real subject of contemplation and study. Now, it is 
quite true that we can only judge of the feelings of others by 
inference ; that which is really known to us is our own feel- 
ing, and nothing beyond ; our own consciousness limits in 
a sense our knowledge. But it is clear that there is much 
beyond our consciousness which it is necessary to examine. 
There is the whole range of mental phenomena exhibited by 
others, whether normal or abnormal. This we must study 
objectively, as we see it exhibited. But we may also bring 
to our assistance that knowledge which we derive from the 
contemplation of our own feelings and existence, always 
keeping in mind, that although this helps us much in the 
examination of the minds and consciousness of others, such 
examination must ever be imperfect, and the wider the dif- 
ference between ourselves and the individual we are study- 
ing, the less correctly shall we be able to analyze the feelings 
of the latter by the light of our own. Pre-eminently is this 
the case in the consideration of the insane mind. People 
cannot comprehend how an insane patient can do this, or 
say that, because they judge of his disordered feelings by 
their own. And if he does or says certain things as they 
would do or say them, they argue that his mind must be in 
all respects similar to their own. 

By experiment and observation, by post-mortem examina- 
tion and vivisection, we connect the movements and actions 
of other beings with the functions of the various organs of 
the nervous system, and we infer from such examinations 
that there are in ourselves also a brain and nerve organs, a 



36 OF THE ORGANS OF MIND. 

fact of which consciousness reveals nothing. Examining 
experimentally the actions of other living creatures, we 
arrive at the conclusion that they consist of contractions of 
various muscles or groups of muscles brought about by 
nerves emanating from nerve centres, which centres are 
stimulated by impressions conveyed to them by other nerves 
coming from the periphery. Thus, it appears that every act 
is the result of a stimulation of a nerve centre, which in turn 
gives rise to a movement. The stimulus may act directly 
from without — as light, or sound, or touch ; or it may be 
central and mental ; it may be conscious, in which case some 
present feeling, either by itself or united to the experiences 
of the past, gives rise to conscious action ; or it may be un- 
conscious, as what w r e call automatic or reflex action : yet 
the law is the same, that from the conscious or unconscious 
stimulation of some nerve centre the act arises. The move- 
ment is all that we experimentally can observe and know; 
the feeling that accompanies the stimulation we can only 
conjecture ; and although we can learn much from the in- 
formation afforded us by other men, by comparison of our 
own feelings under similar circumstances, and by the evi- 
dences of pain or pleasure displayed by children and animals 
on the application of various stimuli, yet there comes a point 
when we can only surmise, and that doubtfully, concerning 
the presence or absence of feeling and consciousness in beings 
other than ourselves. Hence arise the different opinions of 
authors upon the presence of " mind " in certain animals. 
We can observe the progressive development of movements, 
and the increasing specialization of the organs, and the acts 
of the lower animals ; but when we try to determine their 
feeling, or consciousness, or mind, we are driven to conjec- 
tures and arguments from analogy, without having any facts 
or foundations to rest our theories upon. One writer makes 
"mind" coextensive with nervous action, and sees " mind " 
in the movements of a headless frog ; another sees in this 



OF THE ORGANS OF MIND. 37 

not " mind," but " consciousness ;" another, " reflex action." 
Now, it is plainly a mere affair of words to discuss the ques- 
tion whether such movements imply mincl or consciousness. 
And similarly with regard to animals low in the scale of 
creation, one person says that those which have no cerebral 
hemispheres have not mincl, but mere sensation, their acts 
being sensori-motor. Another attributes to them mind, see- 
ing purpose and deliberation in their acts. On this point, I 
would say that, doubtless, they have mind — a mind not 
specialized, as in our own or that of higher beings, but one 
suited to their life and surroundings, and endowed with a 
capacity of feeling in accordance with the excitations of their 
daily life. But to argue concerning all this from the analogy 
of our own mind and consciousness, will only lead us further 
and further from the truth, and blind us to that which we 
can really see and determine objectively. 



LECTURE IT. 

The Phenomena of Mind — The Growth of Mind — The Divisions of 
Mind — Ideas — Feelings or Emotions — Emotions Correspond to 
Ideas — Feelings vary according to the Condition of the Centres — 
Will — Conditions Necessary for the Right Operation of Mind — A 
Healthy Blood-flow — Food — A Normal Temperature — Light — Sleep. 

In considering the objective or physiological aspect of 
mind, we speak of nerve centres and nerve fibres, of stimuli 
conveyed by the latter to the former, resulting in movements 
visible to the eye, but we must now consider such mental 
phenomena as feelings and ideas. In treatises on insanity, 
you will see, as I have already said, such expressions as 
"emotional" or "volitional" insanity. If you turn to 
works on the mind, you will see the latter divided into the 
intellect, the emotions, and the will ; and therefore I am 
bound to speak of these subjects. But what I have to say 
will be as brief as possible, my object being to point out 
what questions are essential for you to examine previously 
to entering upon the study of insanity, and what, in fact, are 
the component parts of that which we call mind, and which 
may be at times disordered, if the conditions of its healthy 
working are not fulfilled. 

The first remark that I shall make with regard to mind 
is, that it varies greatly at different periods of life ; that we 
are not born with it, but that it is developed by slow degrees 
and by the aid of our external surroundings. Our study of it 
must be carried on not only in adults of fully developed and 
perfect mind ; we must also observe all its imperfect mani- 
festations and developments in children, idiots, and the 



THE PHENOMENA OF MIND. 39 

savage dwellers of uncivilized lands, and compare these with 
minds diseased and disordered, and with the still less devel- 
oped mental functions of the lower animals. 

Let us take an infant and see what its brain functions are, 
and how they grow into the full intelligence of manhood. 
You have probably heard of the controversy as to innate 
ideas, a sense of duty born with us, and the like. But infants 
are not born with ideas and knowledge. They acquire ideas, 
but they are born with a brain, and the power of developing 
the function of it, and of acquiring knowledge. The brain 
they inherit, but their acquisitions must depend on its 
healthy working, and on their surroundings and opportuni- 
ties of receiving ideas. We shall find no intelligence at first; 
an infant's nerve phenomena are those of bodily feel- The growt h 
ing and sensation rather than of mind. It passes a ofmimL 
considerable portion of its time in sleep: when hungry or 
cold, it wakes and cries; when fed and warm, it sleeps again. 
It sees nothing, in our sense of the word; the rays of light 
strike on its eye, and, according to the intensity of the lumi- 
nosity, it receives an excitation, pleasurable or painful, of the 
organ of vision. So we find that when exposed to a very 
strong light, it cries, but in the dark it is often pacified by 
being brought in view of a lighted candle. Thus, although 
the infant cannot be said to have any true perception of ob- 
jects, we infer from its movements that it experiences certain 
feelings of pleasure or pain from the excitation of its faculty 
of vision, and the changes produced in the vision-centres. 
As time goes on, it habitually sees certain things, some more 
agreeable than others, as its mother and nurse. Not only is 
the sight pleasant at the moment, but the object remains 
fixed in the memory, and a pleasant feeling is associated with 
it. The child recollects the mother, and the sight of her 
arrests its tears, even before the wished for nourishment is 
afforded. Here it experiences pleasure from seeing a well- 
known face, — a great advance from the time when it was 



40 THE PHENOMENA OF MIND. 

pleased by a certain amount of light, the pleasure being, how- 
ever, the stimulation of a portion of the brain through the 
eye. 

Similarly, if we examine the sense of hearing, we find 
that at a very early age it can hardly be said to exist. The 
infant's slumbers are not disturbed by a noise that would 
wake adults. Yet, when awake, a violent, sudden or harsh 
sound will cause it discomfort; a soft, rhythmical, or musical 
one will please, especially if it come from some familiar per- 
son, as the singing of its mother or nurse. Then the sound 
becomes associated with the individual, and it testifies delight 
at the voice, even when the speaker is out of sight. When 
first it begins not merely to recognize sounds, but to recollect 
names, it associates the latter with certain concrete objects, — 
with a horse, a dog, or a cat; and as each of these objects 
when seen causes a feeling of pleasure or the reverse, so does 
the memory of it cause the same, when laid up in the mind 
under the name associated with it. 

There can be no question that the great majority of objects 
which are laid up in the memory are taken into the mind by 
the avenues of the senses of sight and hearing; yet the 
experiences of taste, smell, and touch are registered in the 
same way, though they are not so multitudinous and varied. 
Those who are so unfortunate as to have been born without 
one or both of the former senses bring the latter three to 
their aid in a degree which others who have no such need of 
them can hardly appreciate. However they enter, whether 
by sight or hearing, taste, touch, or smell, all impressions 
are conveyed by the senses to the brain, and are there stored 
away and associated together, and so become food for thought 
and reflection, and thus we attain to a thinking mind. Till 
this comes to pass, the young infant is much in the condition 
of the animal whose hemispheres have been removed. It 
passes most of its time in sleep, cries when in pain, follows a 
light with its eyes, and executes such movements as sucking. 



THE PHENOMENA OF MIND. 41 

All these ideal feelings stored up in the child's memory 
have, as I have said, come to it from without, and have for 
the most part been associated with some feeling either of 
pleasure or pain at the time they were perceived. The 
excitation of vision representing the nurse is associated with 
the pleasurable sensation of appeased hunger, and so the two 
are connected afterwards, and the sight of the nurse gives 
pleasure, and also recalls the gratification of the hungry ap- 
petite. The association of such ideas is plain enough, and it 
must be that certain portions of the brain corresponding to 
these are also associated, and give rise to associated action. 

A child a twelvemonth old shakes his head when I ask 
him to come to me : he must have learned by his eye to dis- 
criminate persons, and to know mine to be an unfamiliar 
face ; also he must have learned that unfamiliar faces, i. e., 
strangers, are productive of less gratification to him than are 
nurses and friends. So he dissents by shaking his head; but 
he does not cry as he would have done at an earlier age, or 
as he would now, were I to take him by force : he has 
learned that shaking his head indicates unwillingness, and 
averts the evil. Here is a variety of ideas arising out of 
sight and sound, which must have passed through a number 
of associated brain-centres, and, culminating in a deliberate 
act of volition, finally result in setting in motion the muscles 
that move the head. We see decided will, the outcome of a 
feeling of dislike or distrust, which the sight of a stranger 
has roused, but there is very little that deserves the name of 
intellect. Some degree of memory and association we see 
connected with the stimulation of the organs of sense ; but 
the intellectual powers of a child of this age are below those 
of an intelligent dog. 

If we contemplate the same child at the age of three, we 
see that he has made a vast stride. He has gone far beyond 
canine intelligence and canine powers. Supposing him to 
be one of fair average capacity, mental and bodily, we see in 



42 THE PHENOMENA OF MIND. 

him in a certain stage all the capabilities of adult mind. He 
can convey to others his ideas in intelligible speech ; he can 
commit to memory what he hears ; he can reason and per- 
ceive the consequences of his acts, and can abstain from what 
he would fain do if permitted. He has, it may be, a deter- 
mined will, earning for himself the character of being a 
" wilful" child. His intellect will have greatly developed. 
But what of his emotional phenomena? We find this por- 
tion of his organization more developed still. His whole day 
is devoted to enjoyment, to gratifying his bodily sense and 
appetite, to running about* eating, singing, shouting, and 
amusing his mind by pictures, sights, and play. As the in- 
fant passes its days in sleeping, and feeding, in looking at the 
light, and kicking its limbs in the delight of muscular exer- 
tion, so does the three-year-old child live in the perpetual 
indulgence of his pleasures and his self-feeling. If we ob- 
serve the manifestations of emotion, we shall see that he 
exhibits anger, fear, jealousy, hatred and love, wonder com- 
bined with pleasure or with pain which becomes fear, self- 
importance, and a desire to be first and to have precedence 
in all pleasant things. These all grow out of the mere feel- 
ings of pleasure or pain, which at first constituted the whole 
of the infant's emotional state. 

In this microcosm of humanity, a strong and healthy child, 
you may study without fear of mistake the development of 
mind. You will find no better field elsewhere, and he who 
has learned what mind is from an analysis of his own inter- 
nal consciousness, and has not studied it in the manner above 
mentioned, has only half learned his lesson. 

In the works of modern writers wpon mind, there is a 
general agreement among most of them to divide 

The three ? . ° . ° 

divisions of it into three, the intellect, the emotions, and the 
will; and these are described separately, and spoken 
of as having an independent function. Hence it has hap- 
pened that physiological writers and inquirers, hearing from 



THE PHENOMENA OF MIND. 43 

metaphysicians that there are three divisions of mind, have 
thought it necessary to have three portions of the brain cor- 
responding to the three parts of mind; and we shall hereafter 
find that classifications of insanity have been laid down in 
accordance with the threefold division ; and it has been sup- 
posed that one such portion of the brain might become un- 
sound, the other remaining sound. The separate existence 
of these faculties, however, is more apparent than real. 
That for which an independence has been claimed, more 
than for any, is the will. On this are supposed to hinge the 
questions of free will, necessity, responsibility, and the like ; 
yet, after the examination of the acutest reasoners of all 
ages, what is there laid down concerning it on which men 
are agreed ? Looking at these divisions from the phenome- 
nalist point of view, and considering them as they appear in 
their developing stage in childhood, we may, I think, come 
to some practical conclusions without much difficulty. 

I have already spoken of the storing up in the brain of 
the memories of impressions conveyed thither from 

Ideas 

the external world by the various senses, — sight, 
hearing, taste, or smell. We call these impressions, when 
they are thus stored up, ideas — idlat, the images of the origi- 
nal impressions. The brain receives these by means of its 
machinery of cells and connecting fibres, and deals with 
them, associating them into groups, so that the idea of one 
thing calls up another, which is habitually associated with it. 
The idea of form calls up color ; the sound of a trumpet calls 
up the form of one. And when we have thus filled our 
brain with ideas, we unconsciously compare them, discover 
the simile inter dissimilia, and the dissimile inter similia; we 
advance from the simplex apprehensio of the logicians, the 
mere reception of things, to judicium and discursus, the form- 
ing judgments, and proceeding from certain judgments to 
another founded upon them. For all this it is necessary that 
the organs involved be in sound working condition. The 



44 THE PHENOMENA OF MIND. 

child that sees collects ideas inaccessible to one that is blind; 
the latter's store is so much the less, and ideas of certain 
kinds, as of colors, are absolutely unknown to him ; ideas of 
objects he derives from touch, and this sense becomes greatly 
developed from the increased use he makes of it, and the 
communications of the. various brain-cells in which these 
stores are laid up must be perfect, so that they may all be 
brought to bear upon the formation of a given judgment. 
The man whose memory is good, who has all his knowledge 
available, and can concentrate quickly the whole of it on a 
single point, will form a sound judgment, and is popularly 
said to have all his wits about him. The various operations 
of the intellect, call them what we will, may be reduced to 
those of retaining or remembering, discriminating or sorting, 
and reproducing or creating new ideas or judgments out of 
our previous stock. 

For all this we must have mens sana in corpore sano. 
Perfect intelligence, pure intellect, has been conceived as 
existing without the drawback of corporeity, because we 
cannot but feel that the latter constantly interferes with 
the perfect use thereof. How this comes about, how man's 
intelligence and sound mind are marred by his bodily imper- 
fection, it is the chief object of these lectures to show. 

We have seen that the child, besides showing signs of a 
developing intellect, indicates that it possesses emotions and 
will — that is, it lets it be known that it likes or dislikes per- 
sons and things, and executes various movements in accord- 
ance. This brings me to the consideration of what is meant 
by emotion and will in children and in adults. They are 
constantly spoken of as being divisions of the mind, together 
with intellect. It will, however, be seen that they are some- 
thing very different. 

What we generally call emotion, as rage, terror, or joy, is 
Feelings or the feeling of the higher brain, the pleasure or pain 
emotions. Q £ ^ ie mmc { ? as ordinary pain or its opposite is of 



THE PHENOMENA OF MIND. 45 

the body. It is a physical condition or state depending on a 
certain excitation of a nerve centre or centres, varying in its 
character according to the centres excited ; consequently, as 
the latter are developed in complexity and specialty up to 
the highest point of refined and educated adult life, so will 
the emotions be complex and special in their character. A 
feeling of pleasure or pain coexists, we may almost say, 
with life itself. The humblest animals, far below those in 
which we first find cerebral hemispheres, indicate by their 
movements that their well-being is promoted or retarded. 
The youngest infant testifies to pain. If we use the term 
" feeling " instead of " emotion," we shall better understand 
how much there is in common between the bodily and mental 
feelings, how they are exalted or depressed by similar 
causes. An infant'cries if it experiences bodily pain, or the 
discomfort caused by cold or hunger. Its bodily well-being 
is arrested, and it testifies this by appropriate acts, which are 
in accordance with its nerve development at the time. If 
this development advances no further, and the child remains 
in the condition of the lowest idiot, it may go through life 
without indicating any higher feeling; but if it progresses 
normally, we find in a short time signs of mental feeling in 
addition to bodily. Besides crying, ceasing to cry, and going 
to sleep, which at first is almost all that we can observe in 
addition to the movements of the extremities, we notice that 
it smiles when it sees an accustomed face, and shows in a 
short time by vocal sounds its pleasure as well as its pain. 
In all this we see that an excitation of its centres is followed 
by appropriate movements, which may at first be called vol- 
untary or involuntary, so closely do they follow the excita- 
tion. If, however, we try to discover why a child is pleased 
or displeased, we find that this depends either on the char- 
acter of the excitation, or on its physical condition at the 
particular time. A strong light, too loud a noise, a nauseous 
taste, a prick of a pin, a wound or blow, produce pain at 



46 THE PHENOMENA OF MIND. 

once ; but, besides these, we constantly see that when the 
child . is ill everything causes pain, and nothing brings 
pleasure. It cries even with those it loves best, and will 
not be comforted by its toys, or by any of those things that 
pleased it when in health. We judge of a child's health by 
its emotional state, by its being fretful and cross, or gay and 
hilarious. As it grows in rnind and brain, and lays up a 
store of ideas of all kinds, passing from mere concrete objects 
to abstractions, from particulars to generalizations, we find 
that excitation produces feelings equally varying and ad- 
vancing in complexity and specialty. Herein we shall see 
the difference between one child and another, as between 

one man and another. The educated child, the de- 
Emotions cor- 
respond with scendant of a line of educated ancestors, becomes a 

highly specialized man, with feelings and emotions 
of a refined and complex nature. The savage child — the 
child, that is, of savages — becomes a savage man, and his 
ideas and feelings are, compared with those of civilized man, 
childlike throughout life. He is, like a child, easily moved 
to joy, terror, or rage ; but he is incapable of comprehending 
.abstract ideas, as truth, justice, honor, or of feeling the com- 
plex emotions that belong to such ideas. And as his mental 
manifestations are simple, so we find also that the convolu- 
tions of his brain are simple, alike in both hemispheres, and 
more resembling the brain of the apes than does the compli- 
cated and convoluted brain of an educated European. His 
brain is undeveloped, and his mind is incapable of develop- 
ment. Little by little in successive generations this brain 
may increase in complexity and specialization, but in the 
individual savage this cannot take place. And as one savage 
inherits the simple and imperfect brain of former savages, so 
we shall find that amongst the educated nations\a child may 
inherit the imperfect brain of ancestors who have retrograded 
from the development of civilization^ or who have, from 
disease, overwork, debaucheiy, or drink, become degenerate 



THE PHENOMENA OF MIND. 47 

and fallen. Like the savage child, this one will be incapa- 
ble of attaining the perfection of intellectual and emotional 
life. Either he is so stunted and blighted that he is an 
imbecile and an idiot from the beginning, or when he enters 
upon life he is unequal to contend with the chances of for- 
tune, or his organization is so unstable that every ordinary 
illness disturbs his reason. And even if he does not fall 
into a sudden and marked state of insanity, he nevertheless 
is unlike other people. His notions are warped and eccen- 
tric ; he is destitute of the sense of duty and of right possessed 
by others of his country and social status. S He becomes a 
criminal, if not a lunatic, and hands on to his descendants, 
if he has any, the inheritance of criminality or insanity, 
swelling the ranks of the criminal or the lunatic class^ 
Each of these is a degenerate and degraded section of the 
community, which 'might be reclaimed through several gene- 
rations, if we could select the healthiest specimens, and 
leave the worst to die out, as in fact they often do, in a 
state of sterility] 

In ordinary Health, excitations of our nerve centres pro- 
duce certain feelings, which, though often very complex, may 
yet be all resolved into pleasure or pain. The result of the 
excitation, if it be powerful, is action of some kind — verbal, 
facial, or bodily — or desire for action, which we may repress. 
In the child or the savage this repression is not exercised, 
and there is an immediate display of muscular action demon- 
strating the feeling experienced. More civilized men, from 
other ideas habitual to them, repress these signs if they are 
able. But this they cannot always do, and the pent-up storm 
of rage or grief finds vent in words or action. 

To a centre in its ordinary state any stimulation may be 
at once pleasant or painful; or it may be at first pleasant, 
and may afterwards be so prolonged as to cause pain. 
Familiar instances of the latter occur to every one. The 
exercise in which we at first take keen delight becomes 



48 THE PHENOMENA OF MIND. 

irksome and painful, if continued so as to produce great 
fatigue. We are said to "get tired" in time of almost 
frf^cord- an ything — of music, of conversation, of our amuse- 
ingtothe ments — and hence we see that the particular feeling 
of the cen- aroused by such things depends on the condition 
of the centres at a given moment; and as the 
act follows the feeling, this also will be regulated by the 
condition, whatever it may be. 

A dog let loose from its kennel, a horse turned out of its 
stable into a field, a young child fresh from its rest, feels the 
highest delight in exercising its limbs in jumping and run- 
ning; its centres are full of energy almost spontaneously 
discharged in motion. If, on the contrary, either of them 
does not move at all, or crawls along languidly and de- 
jectedly, we say that it is not well with it. Similarly, if 
accustomed pleasures fail to delight a man, and he is gloomy 
and melancholy without any cause, we know that something 
is amiss. He may have been subjected to stimulation of a 
very painful character, to some grief, or loss or pressing 
anxiety, which has exhausted him, has robbed him of sleep, 
and brought him to this condition. He may have encountered 
some event which has caused so sudden a shock that he may 
have fallen as in a fit, or which may have excited him to 
rage or terror, with corresponding action and consequent 
exhaustion. Even pleasurable emotion may become exhaust- 
ing, if prolonged. Laughter may turn to sobbing, and men 
may faint from intense joy. On the well-being of the nerve 
centres will depend our recovery from the effects of these 
excitations. They must needs violently disturb the balance 
of the brain circulation, which is roused to supply the force 
expended. If the circulation fall and sleep return, all is 
reduced to its former level, and we are said "to get over it." 
But if not, a permanant disturbance may take place. 

Here, then, we may lay down the component parts of that 
which, for our purpose, Ave describe as mind. We see that 



THE PHENOMENA OF MIND. 49 

it is evolved out of feelings, under which name we group 
both the sensations derived from the excitation of our senses, 
and the emotions attending the excitation of ideas or past 
feelings laid up in memory, which being recalled to conscious- 
ness, are united to the feeling of the moment, from whatever 
source this may have arisen. This union of the past and 
present is effected by various processes of reasoning and judg- 
ment, and the carrying out the action consequent upon this 
emanates from what we call will, about which I must say a 
few words. 

Will is not one of the primary divisions' of mind. Our 
mind is composed of feelings present and past, that wnl 
have been produced by the various stimulations 
brought to the nerve centres or cells by the conducting 
nerve fibres. Will is only a process of energizing, which 
these structures possess when in a healthy and normal state, 
— a process which intervenes between the stimulation of the 
centres and the motion which is the ultimate result. If will 
does not intervene, the act is said to be automatic; if will 
directs it, it is voluntary. And when we say that will directs, 
we mean that in our mind we form a deliberate judgment con- 
cerning something which we wish to cany out, and then regu- 
late our movements so as to accomplish this end. Will is con- 
cerned with action of some sort, mental or bodily; it does not 
exist as a metaphysical entity. There is no such thing as will 
apart from something willed. And if we examine the acts, 
mental or bodily, which are the result of deliberate will, we 
shall find that a vast number of our actions are not comprised 
in this category, and that those which really deserve the 
name are the result of the whole collected knowledge of our 
mind. Being what we are, we cannot help acting as we do. 
Involuntarily we avoid that which is painful, and seek that 
wdiich is pleasant. In sudden self-defence or danger, we do 
that which truly is called involuntary. Many things are 
done unconsciously by habit and custom, and if we court 

4 



50 THE PHENOMENA OF MIND. 

danger, or choose the painful rather than the pleasant, it is 
because the ideas and knowledge stored up in our brain 
teach us that it is better for some reason or other so to do. 
People differ in that which they choose to do, because of the 
difference in the general constitution and furnishing of their 
minds. One man can practice great self-denial which 
another cannot. He is enabled to do this, not because one 
part of his brain, inhabited by a function called his will, is 
larger than that of the other man, but because his whole 
mind is stored with feelings and experiences which counter- 
act the impulse to gratify a present desire, a desire not 
resisted by a man less endowed. Our criminal law can 
only be enforced by supposing that all men are alike, even 
to the point of all being acquainted with every law that is 
made; but, practically, we make great differences and allow- 
ances for individuals according to their opportunities, their 
rearing, education, and past history. Were an educated 
gentleman to steal a watch, we should affix to the act a 
stigma very different from that which accompanies the theft 
committed by one who has been reared in vice and crime. 

If we consider what can be done by dint of our will, we 
shall find that willing can do very little per se. We learn 
to walk, we learn to ride, to write, to dance. By long and 
laborious practice we acquire the power of executing such 
movements, and no effort of will can enable us to perform 
them till we have learned the method. When this is 
acquired, such things are done unconsciously. If we apply 
our will to mental operations, frequently we cannot fix 
our attention on one subject for ten minutes at a time, or do 
what we will we cannot exclude an idea from our thoughts. 
We cannot by our will recall a name or a circumstance; and 
when we are conscious of exercising a choice, and of deliber- 
ately resolving to do this or that, it is because our reason, 
judging by the aid of experience of the past, and the prob- 
abilities of the future, based on such experience, indicates 



THE PHENOMENA OF MIND. 51 

that which we must choose. We say emphatically of a man, 
when we wish to assert that he did something freely and 
voluntarily, that he deliberately did the thing; i. e., that he, 
after due reflection and consideration, proceeded to act. 
Therefore volitional insanity must imply an insane reason 
and judgment, not only an insane will, and is no more a 
separate and special form than are ideational and emotional 
insanity, which are supposed severally to represent an insane 
intellect and insane emotions. We can no more divorce in- 
tellect and emotions than we can divorce intellect and ideas 
from consciousness. 

I discard the will, then, as a third component of mind, 
and retain only feelings and ideas, which in truth are not 
two, but one, as they arise from present stimulation, are 
stored away in memory, and in new combinations come again 
into consciousness upon fresh excitations. Under the term 
feeling we may range the bodily sensations of pain or pleas- 
ure, the sensations of the special senses, as the eye or ear, and 
the emotions which are but the feelings of the highest 
centres of the brain concerned with the intellectual, the 
aesthetic, or the religious. For the due operation of our 
feelings and resulting ideas, we require the healthy working 
of the nerve centres, with the system of nerve fibres, 

' J ? Conditions 

and adequate suppty of blood, which I have described necessary 

_ TT1 . . . . . , for the right 

to you. When this goes on aright, our minds are operation of 
healthy; when anything interferes with the proper 
working, we have the evidence of it in an irregular or ab- 
normal manifestation of mind-action. And before I come 
to the subject of insanity as generally understood, it may be 
as well to glance for a moment at a few of the conditions of 
the healthy working of brain and nerve. 

We ma} r sum up in a few words these several conditions. 
Given a healthy apparatus, free from defect, we require for 
its working a clue amount of material in the shape of food, 
to be converted, through the agency of the digestive and 



52 THE PHENOMENA OF MIND. 

circulatory system, into healthy blood, supplying the waste 
in the brain cells. This blood must be in all respects fit for 
its purpose, rich in oxygen and all necessary ingredients, 
and free from all impurities, as urea, bile, carbonic acid, or 
other poisons. Secondly, we require for the due discharge 
of mental action a certain amount of heat. Thirdly, we 
must at stated intervals have a period of rest and cessation, 
which in man is given by sleep. Failing any of these, 
mental action- becomes disordered, and finally ceases. 

The mere amount of blood circulating through the brain 
i. a healthy must of necessity influence to a material degree its 
biooa-flow. p 0wer f acting. Mechanical^, I mean, the pres- 
sure of an undue quantity, or, conversely, the removal of the 
accustomed pressure, must affect the relations and the func- 
tions of such delicate structures as the nerve cells and nerve 
fibres. That pressure can be exerted upon the brain cells 
by increased blood supply is a fact which, I believe, may 
now be considered fully established, though formerly some 
held that this could not be the case. We may concede, how- 
ever, that the amount of blood sent to the brain is, compared 
with that which may be injected into other organs, limited 
by the conditions of the arteries ; nevertheless, it is certain 
that enough may be sent there to interfere with the healthy 
state, for after death we have traces of active hyperemia 
plainly apparent. Another probable result of excessive 
hyperemia and pressure is stasis of the blood in the vessels 
and capillaries: stasis both of the red corpuscles and the 
white, with blocking of the minute vessels, and consequent 
delirium or stupor. Upon this point I shall have more to 
say hereafter; but I wish only here to remind you of the 
writings of Mr. Lister on the phenomenon of stasis in inflam- 
mation, and of Dr. Charlton Bastian's paper, in which he 
describes this blocking as discovered by himself, in a case of 
erysipelas of the head with delirium, narrated in the "British 
Medical Journal" of January, 1869. 



THE PHENOMENA OF MIND. 53 

Into the varieties of food necessary or adequate to the 
proper discharge of brain function I shall not here 
enter. You will have heard of them elsewhere. It 
is a fact of observation that the dwellers in northern regions 
eat quantities of animal food and fat and grease of all kinds, 
which could only be consumed by those who live under such 
climatic conditions, while those who inhabit tropic lands may 
pass through an active life without eating anything save a 
vegetable diet. And this brings me to another head. For 
the due discharge of brain function it is necessary that the 
individual should live in a dertain temperature, not 3 Anormal 
too hot nor too cold. Life — the life, that is, of man temper*. 

ture. 

— can only exist in a certain temperature; and the 
first mode in which the invasion of cold is evidenced is in 
the effect produced upon the nervous system. An over- 
whelming desire to sleep comes over a man exposed for a 
long period to extreme cold; and, as you know, to sleep 
under such circumstances is fatal, unless some one is at hand 
to wake the sleeper. If this be the case, the sleep is benefi- 
cial, and recruits the exhausted powers, showing plainly that 
nervous exhaustion is the condition which the cold produces. 
In his most interesting book of Arctic travel, Dr. Kane relates 
how he and his companions were once nearly lost in the 
cold: "Our halts multiplied, and we fell half-sleeping on the 
snow. I could not prevent it. Strange to say, it refreshed 
us. I ventured upon the experiment myself, making Riley 
wake me at the end of three minutes, and I felt so much 
benefited by it that I timed the men in the same way. They 
sat on the runners of the sledge, fell asleep instantly, and 
were forced to wakefulness when their three minutes were 
out." 1 

The blood must be pure; it must contain no deleterious 
substance which may interfere with the healthy nutrition of 
the brain, or may actually poison it, and set up therein that 

1 Arctic Explorations, vol. i, p. 198. 



54 THE PHENOMENA OF MIND. 

inflammation and stasis which I have alluded to. It must 
not be vitiated by poisons introduced from without, as alcohol, 
opium, lead; neither ought it to contain those poisonous 
matters which, generated within the body, and in a healthy 
individual excreted thence, are occasionally retained, and 
give rise to symptoms of brain disorder, such as delirium, 
coma, or convulsions. 

However we may explain the metamorphosis of other 
forms of motion or energy into mind, it is a fact of experience 
that an adequate supply of food is required for the wants of 
the nervous system, and that a x failure of food results in a 
corresponding diminution of nerve-energy, and often in nerv- 
ous disease. I shall have to return to this again and again, 
believing, as I do, that a plentiful supply of food is of all 
things the most efficacious in restoring exhausted nervous 
power, and in removing nervous disorder. If we read the 
accounts of shipwrecked sailors and others who have been 
compelled to live for some time upon a scanty supply of food, 
we see how weakness was the prominent symptom experi- 
enced, weakness rather than hunger, weakness not to be 
accounted for by the diminution of the muscular tissues, but 
rather by the want of nervous power. Not merely for the 
nourishment of the brain and other portions of the nervous 
system is the food required. It is demanded not only that 
the brain may live, but that it may duly discharge its func- 
tion in a normal and healthy manner. The brain may live, 
and the owner may live for years in a state of the most 
abject fatuity. 

The animals that have to pass the winter in countries 
where the cold is very severe, do so, many of them, in the 
state of hibernation. ,So little is expended in this condition 
of sleep, that often without food they exist for months, with 
all the functions of life reduced to a minimum, the amount of 
nervous energy required for these being derived from the 
blood, which is in turn renovated from the stores of their 



THE PHENOMENA OF MIND. 55 

bodies, or by occasional meals from the supply of winter food 
laid up by some of them. But hibernation is not possible 
for us or for the more highly organized and developed ani- 
mals, and cold deprives us of our nervous power even when 
we are supplied with adequate nourishment. Too great heat 
also incapacitates us from properly discharging our brain 
function, and causes that disorder called coup de solell, which 
has its seat in the cerebral organs. 

Not only is the warmth of the sun beneficial to the health 
and energy of the human mind, the light of it is also 
essential to its well-being. The protracted darkness 
of northern countries has been observed to bring about in- 
sanity, especially melancholia. Dr. Lauder Lindsay draws 
attention to this in a paper on " Insanity in Arctic Countries," 1 
to which I refer you. And Dr. Kane, from whose book I 
have just quoted, mentions the depressing effect of darkness, 
which affected, he says, even the dogs, though they were born 
within the Arctic circle. A disease which he considered 
clearly mental, affected them to such a degree that they were 
doctored and nursed like babies. They ate and slept well, 
and were strong, but an epileptic attack was followed by true 
lunacy. Of course, we cannot, in speaking of Arctic countries, 
eliminate the joint effect of cold, fatigue, and want of fresh 
food ; but in other countries, in cities, dungeons, and else- 
where, the depression caused by prolonged darkness has been 
felt and noticed. 

• For the due discharge of its function, our brain requires 
rest, which rest it takes in sleep. Only in complete 
sleep does it thoroughly recruit itself, and lay up 
stores of energy to be expended in the waking hours. In 
sleep all work ceases save the processes of organic life, and 
these are reduced to the lowest point. There is no expendi- 
ture, but, on the contrary, there is constant renewal of nerve 
power. According to the exhaustion and previous waste of 

1 British and Foreign Medico-Chirurgical Review, January, 1870. 



56 THE PHENOMENA OF MIND. 

power will be the demand for sleep and the continuance of it. 
Men become so worn out that the strongest impressions, the 
loudest noises, or the most exciting news, cannot avert the 
sleep that comes over them ; but the amount that will refresh 
them varies greatly in different individuals. Some require 
much sleep, some little ; at times a brief snatch, even of a few 
minutes, will greatly recruit the wearied man. I As you study 
insanity and observe insane patients, you will have to be con- 
stantly w r atching the phenomena of sleep and sleeplessness. 
You will see the consequences of the entire loss of sleep, of 
the partial loss. You will meet with some whose minds break 
down because their brain is constantly and habitually over- 
worked by day, and not sufficiently renovated by sleep at 
night. I Either their work pursues them into the night, and 
haunts their couch and disturbs their sleep by harassing 
thoughts and grave responsibilities, or they allow themselves 
an amount of sleep altogether out of proportion to that de- 
manded by their daily task. 

Such are the subjects to which I wish you to direct your 
attention before you enter on the study of the disorder termed 
Insanity, or unsoundness of mind. I have brought them 
under your notice roughly, not with the accuracy and perfect 
delineation of a photograph, but as men draw diagrams on a 
black-board, giving in broad outline just so much as will 
illustrate what they have to describe. You must bear in 
mind that you have to consider the nerve centres and the nerve 
fibres which connect them to each other and to other parts, 
the blood which furnishes them with life and energy, the 
bloodvessels that carry this to them and take it away, and 
the nervous system that regulates the supply ; the nature of 
the resulting operations, whether of mind or motility, and 
the conditions under which they are carried on. Such are 
the data. When these organs all work harmoniously and 
healthily, sound mind is the result. When the mind is un- 
sound, we must discover the defective spot in one or the other 
of these parts or processes. 



LECTURE III. 

The Pathology of Insanity — Characteristics of Commencing Insanity — 
Varieties of Insanity — Insanity from Mental Shock — From long-con- 
tinued Anxietjr — Insanity in connection with the Sexual Organs — 
Puerperal Insanity — Insanity of Masturbation — Insanity of Alcohol 
— Various Forms — Insanit}^ from other Poisons — From a Blow — 
From Excessive Heat. 

Havixg thus glanced at the phenomena of healthy mind, 
we are in a position to study those of unhealthy or disordered 
mind ; having laid down the physiology, we proceed to the 
pathology. 

Now, by dail^y intercourse with sane people we know very 
well what is meant when in ordinary phraseology 

. . . m t Soimdmind - 

we speak of a man as being " right in his mind. It 
is assumed that, being of full age, he has stored his brain 
with a reasonable amount of knowledge and of facts of ex- 
perience; that he can recall a fair proportion of what he has 
seen and heard during the past years, and can act upon this 
experience in an intelligent manner, giving good reasons for 
so acting; that he can understand what is said to him upon 
subjects within his comprehension and knowledge, and dis- 
play judgment in what concerns him personally. Such is 
what lawj^ers call a man "of sound mind, memory, and 
understanding." Conversely, we say a man is " un- unsoundness 
sound of mind" when he forgets most of what hap- ofmind - 
pens to him; can form no judgment from what he has seen 
or learned ; when his acts are outrageous, and he can give 
no good reasons for them ; when his ideas concerning himself 
are palpably false, i. e., delusions; or when he is quite uncon- 
scious of what he is doing. 



58 THE PATHOLOGY OF INSANITY. 

According to the nature of the defect, we say that he 
is idiotic or imbecile, insane or delirious. These forms of 
unsoundness of mind may vary in degree, and no less in 
duration, lasting from hours to years. Yet, certain it is that 
they depend on alteration or defective action of those organs 
I spoke of in my first lecture, the nerve centres and con- 
ducting fibres, the bloodvessels, and the system by which the 
supply of blood is regulated. Unsoundness of mind may 
exist by itself, the bodily functions being apparently intact; 
it may be coupled with epilepsy, apoplexy, and other cere- 
bral affections, or arise in the course of such diseases as 
measles, pneumonia, acute rheumatism, and fevers of all 
kinds, or may be traced to blood-poisons, to alcohol, hasch- 
isch, or opium. Whether we call it delirium, coma, wander- 
ing, or idiocy, mania, melancholia, or dementia, it depends 
on some pathological condition of the nerve centres, and 
implies a total or partial mental alteration or defect. 

Having thus widened out the subject to the full, I must 
proceed to consider some of the details, for it is not within 
the scope of these lectures to examine seriatim every one of 
the conditions just enumerated. I pass over idiocy and con- 
genital idiots, whose undeveloped organs and faculties are 
incapable of receiving the data of experience, and of forming 
out of them judgments. I leave to other teachers the con- 
dition of coma, which is rarely seen by those who observe 
the insane, except when it is the precursor of death. That 
to which I chiefly wish to direct your attention, and which 
is involved in the greatest obscurity, is the alteration which 
takes place in the mind of a man previously sane, and in a 
longer or shorter time may pass away, leaving him sane as 
before. The alteration may be so transient, and the restora- 
tion so complete, that it is impossible to believe the patho- 
logical change can be anything more than what is usually 
called " functional." 

If you look carefully at a number of patients whose in- 



THE PATHOLOGY OF INSANITY. 59 

sanity is just in its commencement, you will find ckaracteris- 
certain characteristics in which they agree. I do ticsofcom - 

■' u mencmg m- 

not mean that they will agree in their delusions, or sanity. 
that they will perform the same acts, but certain physical 
symptoms will be observable in all, which point to patho- 
logical disturbances of nerve function. 

a. The first I shall mention is, that very few, if any, such 
persons sleep in a normal or natural degree. Almost a Want of 
invariably, sleep will be in defect. This defect, this sleep - 
sleeplessness, may be greater or less according to the severity 
of the case, varying from entire loss lasting for days, and 
threatening danger to life, to an amount which, though less 
than usual, yet brings some renovation of strength to the 
sufferer every twenty-four hours. 

b. Another symptom not so universally present, which 
may be overlooked by you, or denied by the patient, b Pain) or 
is pain and heat of head, frequently a flushed face, heatofnead - 
throbbing of the carotids, and suffused eyes. 

c. Next, and this I think of the greatest importance, there 
is almost always an alteration in the general emo- 

. ... c - Alteration 

tional condition of the individual. It has been said in emotional 
that in all insanity there is at first a period of de- 
pression, to be followed in mania by excitement. This I 
doubt. I believe that excitement may be the first change 
noticeable; but I think it certain that one or other, depres- 
sion or excitement, a departure in one or other direction 
from the normal emotional state, may be observed in most 
patients at the commencement of an attack. Friends will 
tell you that a man has become quiet and dull, or restless, 
irritable, or excitable, and this in many instances long be- 
fore any marked intellectual disturbance or delusions are 
manifest. These are all symptoms which are the common 
precursors of insanity, and I wish you particularly to recol- 
lect them, because they throw light on the nature of this 
terrible malady, and by keeping them ever before your eyes 



60 THE PATHOLOGY OF INSANITY. 

you may be able to avert the threatening evil; for we are 
reproached because we never attempt to deal with insanity 
till it has fully and unmistakably declared itself. There is 
no need to consider these symptoms separately; in speaking 
of one I shall touch on all. 

If my views are correct, this depression or exaltation, this 
emotional alteration, points not to a disturbance of one por- 
tion of the brain, but to a pathological condition of the whole 
nervous system of the highest significance. You will find 
it called by some "emotional insanity," and will read that 
the emotional part of the mind may be disordered, the intel- 
lectual remaining sound, and delusions not being observable. 
This distinction cannot, I maintain, be upheld. Patients 
may, or may not, have delusions ; they may have the same 
delusions, and yet be very different in their feelings concern- 
ing them ; the delusions are the result of the emotional and 
general condition, not the cause, and this explains our find- 
ing almost identically the same delusions in so many pa- 
tients ; for the emotions are the result of alterations of the 
health and energy of the entire nerve centres, and accord- 
ingly the man is depressed or excited, angry, noisy, or hila- 
rious. 

This feeling of depression or gayety is apt to be overlooked, 
because it is such a common occurrence, but as we daily feel 
it ourselves, or witness it in others, we can understand that 
it is a physical condition depending upon the general bodily 
health. We never think of attributing it solely to mental 
causes. Without anxiety or care of any kind, a man may 
feel low ; another even under a load of trouble feels cheerful 
and elastic. We talk of an " attack of the spleen," of being 
"jaundiced," of the liver being out of sorts, or the stomach, 
but we don't call our ailment " disorder of the brain," nor is 
this in many cases the part primarily affected. Quite pos- 
sibly the digestive organs may be the seat of the mischief, 
and an alteration of diet or a dose of medicine may effect a 



THE PATHOLOGY OF INSANITY. 61 

cure. Our fathers used to recognize this when they wrote of 
u visceral sympathies." Little is known even now of the 
relations of one organ to another, or of the sympathetic dis- 
turbances, so that we cannot always fix upon the peccant 
part. 

d. After the stage of emotional alteration has begun, 
sooner or later in the majority of patients delu- d gubge _ 
sions, or hallucinations, appear. In some we may quentiy, 

. . delusions. 

not be able to discover any which merit the name. 
Of such I shall speak hereafter ; but, as I have said, in most 
patients who are insane, and not imbecile or delirious, we 
shall find delusions, false and erroneous notions about them- 
selves and their relations to other people and things. A 
part of the mind appears to be out of joint; it does not work 
in harmony with the rest. Being perfectly clear on many 
points, they assert what is utterly false or impossible con- 
cerning others, and all demonstration fails to point out that 
they are mistaken. They are unable to compare their feel- 
ings with the facts of their own or others' experience ; and 
with these delusions there may be every variation of emotion, 
from the profoundest gloom to the liveliest hilarity. For- 
merly insanity was divided according to the feeling displayed, 
and for ages writers knew no classes but melancholia and 
mania. As a reaction which might have been expected, 
pathologists nowadays say that this is no division at all ; that 
it is but an accident if a man is melancholy or the reverse. 
As usual, the truth is somewhere between ; the melancholy 
of a patient is a pathological condition different unquestion- 
ably from that of a man in gay and noisy mania, and requir- 
ing different treatment. But the whole pathology is not 
summed up in either of these terms. Two women, from the 
same cause, parturition, will become, the one maniacal, the 
other melancholic. It is not sufficient here to set these down 
as suffering from puerperal insanity. We must look for va- 
rieties in the conditions which may account for the varieties 



62 THE PATHOLOGY OF INSANITY. 

in the phenomena exhibited. It has been proposed to classify 
insanity according to its causes. But it is entirely unscientific 
to describe the condition of a patient by simply naming an 
origin, possibly very remote, and to take no account of all 
the various steps by which the patient has advanced up to 
the time of our examination, or of the phenomena exhibited 
^ , , at the latter period. Again, we shall find that in- 

The form of *■ ° 7 

the insanity sanity is for the most part the outcome of a number 

depends on . . 

a number of ot causes, not ot one ; and this, it true, would at 
con nons. once v itiate such a classification. That which is 
above everything needful is a consideration of the whole pa- 
thology of a patient at the time of the first manifestation of 
mental disorder. At this time we shall be best able to ap- 
preciate his exact condition, and to trace the course of the 
malady thence, mindful of the essential, and setting aside 
the non-essential phenomena thereof. In considering the 
pathology, we must also be studying the cause. The precise 
pathological condition may be hard to discern, yet the attempt 
must be made, and constant practice will enable us to do 
much. 

If we consult the works of the chief writers upon the sub- 
ject of insanity, we shall see that the varieties of the disorder 
are in almost every case determined by the mental symp- 
toms ; and so we find ever recurring the old divisions of 
mania, melancholia, and dementia. In describing the causes, 
we hear of other physical conditions, e. g., insanity brought 
about by epilepsy or syphilis, but the varieties or classes are 
usually not distinguished by pathological diversities, but by 
mental peculiarities only. One exception, however, I must 
mention. In 1-863, Dr. Skae, of Edinburgh, read before the 
„ D1 , Medico-Psychological Association a most suggestive 

Dr. Skae's «/ ° °° 

pathological paper on " A Rational and Practical Classification 

classification. .,,,.,. . , . -, x -i r» 

or Insanity, which is printed in the "Journal of 
Mental Science." His scheme he puts forward not as com- 
plete, " but as one which may, by combined efforts, culminate 



THE PATHOLOGY OF INSANITY. 63 

in a better, a more definite, and, at least, a more practical 
method than the one in present use." I look upon this 
system as so valuable, both on account of its own merits, 
and as the precursor of all that will certainly follow, that I 
cannot but transcribe it here. It is this : 



Idiocy, -i Intellectual. 
Imbecility, J Moral. 
Epileptic Mania. 
Mania of Masturbation. 

" Pubescence. 
Satyriasis. 
Nymphomania. 
Hysterical Mania. 
Amenorrhoeal Mania. 
Sexual Mania. 
Mania of Pregnancy. 

" Lactation. 

" Childbearing. 



Climacteric Mania. 

Ovariomania (uteromania). 

Senile Mania. 

Phthisical Mania. 

Metastatic u 

Traumatic " 

Sunstroke " 

Syphilitic Cl 

Delirium Tremens. 

Dipsomania. 

General Paralysis of the Insane. 

r Sthenic. 
Idiopathic Mania < A ., 

* (. Asthenic. 



The merits of this division are so great, and its superiority 
over all preceding so manifest, that it requires little or no 
comment. Without being a classification based exclusively 
on etiology, it yet takes into consideration the pathological 
condition of the individual, and the origin of the disorder. 
One could have wished that Dr. Skae had gone one step 
further, and banished altogether the word mania, which he 
apparently uses as synonymous with insanity ; but which, in 
common parlance, conveys the idea of a peculiar mental state. 
Idiopathic mania, sthenic and asthenic, conveys no patho- 
logical meaning, and is, if anything, misleading. Schroeder 
van der Kolk, it is true, divided all insanity into idiopathic 
and sympathetic, the former arising, as he supposed, in the 
brain, the latter being caused by sympathetic disturbance of 
the bodily organs ; but such vague divisions have no practical 
value, pathological or therapeutical. As I shall hereafter 
point out. the insanity which has no apparent cause might 
almost invariably be termed hereditary, were it not that 
much more than this may as truly be called hereditary, the 



64 THE PATHOLOGY OF INSANITY. 

exciting cause only lighting up the transmitted and latent 
disease. Both Drs. Skae and Schroeder van der Kolk pass 
over too lightly the influence of hereditary taint. The path- 
ological condition observable in a patient at the outbreak 
of insanity has its origin, in numberless cases, not in the in- 
dividual, but in his ancestors, and no classification or patho- 
logical description can be exact which omits to take this 
great fact into account. 

I will jmss under review some classes or conditions which 
varieties of are ? as I conceive, pathological varieties, and you 
insanity. w -jj k e a kj e ^ Q com p are them with Dr. Skae's system, 

and will see how large a part is played by that hereditary 
insane temperament to which I have just alluded. I shall 
hereafter have something more to say on the subject of class- 
ification. At present, without professing to lay down all the 
classes of insanity, I will consider the pathology of certain 
groups of cases, which I believe differ from one another in a 
pathological point of view. 

The first is disorder of the brain produced by a mental 

shock, with sleeplessness, heat of head, depression, 

from mental or painful excitement, which may be accompanied 

sliock 

by confusion of thought or delusions. Sudden shock 
may be followed by a variety of grave consequences, by death 
if there be heart disease, by apoplectic effusion of blood, by 
epilepsy, by chorea in young persons, and by various forms 
of insanity, from acute mania to what is termed acute de- 
mentia. 

Most men know what it is to have been kept awake for a 
considerable portion of the night by something which causes 
them anxiety or grief. There is a strong stimulation of the 
mind, causing continued thought, and followed by an excited 
brain circulation. Even the anticipation of pleasure may 
produce the same result. In the young this may more fre- 
quently be the disturber of sleep than care or sorrow, which 
comes to them seldom, and sits on them lightly. From one 



THE PATHOLOGY OF INSANITY. 65 

cause or other almost every one knows what it is to be rendered 
sleepless. Now, if we observe the succession of phenomena 
in persons of ordinary health, what do we find? The re- 
ception of a mental shock causes immediate activity of brain, 
rapid molecular change in the centres, and in consequence a 
determination of arterial blood to the head. Even muscular 
structures may be set in motion, and this involuntarily. 
Very likely there will be trembling, or sobbing, or crying. 
The sufferer may pace the room, or rock himself, or wring 
his hands. All such acts imply a continued change going on 
in the centres; and they also imply a want of controlling 
power. The weaker the individual, the more violent will be 
these manifestations. Take the first, trembling. This indi- 
cates a lack of force. If we hold out a weight with extended 
arm, a weight too heavy for our strength, our hand trembles 
more and more, till it falls exhausted. The muscles do not 
balance one another, and the emission of force is jerky and 
uneven; the organs are not co-ordinated. The same tiling 
may be said of convulsions, which so frequently occur after 
hemorrhage or other exhausting causes. As the power of the 
centres becomes exhausted, it is manifested by the irregular 
and spasmodic action of the muscles, which are set free from 
one another, and act separately and uncontrolled. A common 
sequel of shock is chorea, which is another variety of this 
spasmodic action. The defect of power in this disorder is 
fully recognized, and it has been supposed that the sole cause 
of it is embolic closure of the arteries. Without examining 
the question, I may assume that there is defect of power, 
whether depending on exhaustion of the normal supply, or 
deficiency of the blood whence it is derived. I believe both 
conditions may be found. 

In ordinary health sleep comes to the disturbed brain after 
a longer or shorter period, the sufferer wakes refreshed, and 
on the next day his mental disquiet wears a very different 
aspect. But in a man doomed to insanity the rapid molec- 



66 THE PATHOLOGY OF INSANITY. 

ular changes do not cease, sleep does not come, and soon 
there is evident emotional change, with confusion and want 
of co-ordination of ideas. 

The form of the insanity will vary according to the condi- 
tion of the whole nerve centres of the individual ; in a young 
and vigorous subject it will most likely take the form of 
mania, with violent ebullitions of anger, and much muscular 
action ; in the old or weakly, melancholia more commonly 
appears ; while in one whose nerve power is for the time 
utterly prostrated, there will be some such variety as acute 
dementia, or melancholia cum stupore, where mind is a blank, 
and voluntary action altogether gone. That the patient pre- 
sents this or that kind of mental disorder is, it is true, in one 
sense an accident. The exciting cause may produce in one 
man melancholia, in another mania; but I hold that the con- 
dition called melancholia is very different pathologically from 
that of mania. The first pathological condition, then, for 
your consideration and study is that of insanity caused by 
sudden mental shock, a rapid molecular change being set up 
in the brain, giving rise to accelerated circulation, heat, and 
want of sleep, with the phenomena of emotional disturbance 
and confusion of thought and idea, the symptoms varying 
according to the general constitutional energy of the indi- 
vidual. Here, to use an old expression, we may say that the 
circulation is disturbed by a vis a fronte, or, using another 
formula, ubi stimulus, ibi fluxus 7 we indicate that the changes 
which bring about the increased blood-flow have commenced 
in the organs of mind under the influence of undue stimula- 
tion from without. 

I now come to a second pathological condition, where not 
2. insanity a sudden mental shock, but a long-continued mental 
from long- worr y or anxiety, or Ions; and laborious mental ap. 

continued •/ • •/ ^ o j. 

anxietyor plication and work, has overset the reason. We see 

the result of this very frequently in brain diseases 

other than insanity, in so-called softening and disorganiza- 



TEE PATHOLOGY OF INSANITY. 67 

tion of structure, produced by years of overwork. Here the 
machine gradually wears out; but in another, whose brain 
function is more liable to disturbance, there may be at an 
earlier period signs of disorder rather than of decay. The 
carking cares of poverty, and the lack of means to support a 
family, the chronic torment of a bad husband or wife, or of 
prodigal sons or profligate daughters, constant harass and 
anxiety in businesses of a speculative character, or a per- 
petual craving ambition perpetually disappointed, — these 
and a thousand other miseries of human life are the things 
which upset reason and fill asylums. And what is the pa- 
thology here ? We do not hear of a sudden mental shock 
causing an overwhelming emotional excitement, and bring- 
ing about almost at once sleeplessness and acute insanity. 
But we know that there must have been a constant stimula- 
tion of the brain, with increased emotion and increased ex- 
penditure going on for years. The brain circulation during 
all this time has been disturbed, and the nerve centres ex- 
posed to a greater demand and a greater amount of change 
than they are able to bear. Some men may endure this, 
may work early and late, and retain their faculties unharmed; 
but others, who are by nature more prone to change, 
who easily display emotional excitement, and do not easily 
subside into their normal calm, are one day excited beyond 
recovery, and insanity is manifested. Owing to the length 
of time that the stimulation has existed, and the consequent 
weakening and exhaustion which the whole of the machinery 
must have undergone, we find that this form of insanity does 
not usually subside rapidly, and too often see along with it 
signs of irremediable disorganization of the brain or the 
nutrient bloodvessels. 

It follows that these patients are not very youthful, and 
as long-continued and exhausting anxiety is the main cause, 
we should expect melancholia to be the form the insanity will 



68 THE PATHOLOGY OF INSANITY. 

take, or monomania, with suspicion and ill temper, rather 
than violent sthenic mania. 

Whereas one section of observers ascribes to u moral causes " 
the chief role in the causation of insanity; another, looking 
farther back, would deny to them any status in this regard, 
and would reduce all to physical causes and conditions. And 
with some reason ; for in almost all the cases where insanity 
follows a mental trial, we shall detect in the physical con- 
stitution of the individual a predisposition, an instability of 
nerve constitution, which enables the mental cause to over- 
throw him. We must consider, not the events of the pre- 
ceding month or year, but the history of the individual from 
his birth, and that of his parents before him. There are men 
who, with the misfortunes of a Job, or the anxieties of a 
Damocles, are nevertheless calm, equable, and active, ever 
ready to catch the turn of the tide, prepared for everything, 
good or bad ; and, on the other hand, some fall down before 
the slightest buffet of fortune, and are said to be driven mad 
by grief, or loss, or worry. A man may have griefs and 
anxieties so severe as scarcely to fall short of disease; but 
the moral causes of the insanity of many are of so slight a 
nature, when looked at objectively, that it is at once clear 
that other causes and conditions must be sought. I have 
said already, and shall have to repeat it again and again, 
that insanity is the result of a number of events and con- 
ditions which go to make up one pathological state. To 
gather all these together is probably out of our power, for 
we should have to survey a series of phenomena of infinite 
extent, and far beyond our ken. 

In a large number of cases we cannot help considering, in 
connection with the insanity, some condition of the 

3. Insanity m ^ 

in connec- sexual organs, which, whether it be the cause or the 
the sexual concomitant of the mental symptoms, must at any 
organs. ra ^ e ^ e viewed as part of the pathological state of 
the patient. Women become insane during pregnancy, after 



THE PATHOLOGY OF INSANITY. 69 

parturition, during lactation; at the age when the cataraenia 
first appear, and when they disappear. Excessive indulgence 
either in venery or masturbation are causes admitted by all, 
and there are other less defined varieties, known as satyr- 
iasis, nymphomania, and hysterical mania, of which the 
pathology is often obscure, and into which many various 
conditions enter. Also we may trace, or think we can trace, 
the brain disorder to such maladies as tumors -of the womb 
or ovary, or to sudden suppression of the catamenial func- 
tion. Here, then, is a large group necessarily somewhat 
allied, the pathology of which must be studied as a whole, 
partly by observation of cases, partly by the analogies of 
other pathological conditions of insanity, or other nervous 
disorders traceable to the same causes. 

The sympathetic connection existing between the brain 
and the uterus is plainly seen by the most casual observer. 
Many women are completely prostrated while menstruating, 
and suffer intensely in the head. In many animals the 
analogous period of the rut produces mental phenomena 
which approach insanity as nearly as anything evinced by 
these lower minds can. The madness of March hares has 
passed into a proverb. The stag and the buck, in October, 
render unsafe the parks in which they dwell. In a woman 
whose brain is peculiarly unstable and prone to disturbance, 
it is no wonder if uterine irregularities cause corresponding 
mental symptoms. 

If we consider the insanity that makes its appearance at 
the time of pubescence, what may be observed ? a Insan i ty 
First, that this period brings more dangers to girls of i jubert y- 
than to boys ; that more girls between the ages of twelve 
and eighteen become insane than boys. This we should ex- 
pect. The period of pubescence causes a greater functional 
change in a girl than in a boy, with an increased risk of func- 
tional disturbance. A boy grows into a man imperceptibly, 
as it were. His development is marked by a capacity of 



70 THE PATHOLOGY OF INSANITY. 

procreation ; but this is something very different from the 
establishment of the menstrual function, which so often is 
attended by great general disturbance. We may assume that 
at this time every girl is in a condition peculiarly susceptible 
of nervous irritation ; therefore, in one who inherits from 
her ancestors an unstable organization, two conditions exist 
very favorable for the production of mental disorder. These 
may be of themselves sufficient to originate it; but there 
may be superadded either a mental cause, as a fright or a 
loss, something startling, harassing, or afflicting, a dreary, 
companionless, and cheerless life, a physical disorder, as 
menorrhagia, or an illness of an acute character. 

You will find that such a conjunction of causes does not 
always produce insanity in a girl or boy : it may produce 
chorea : instead of the highest mind-centres being affected, 
there is disturbance of the motor centres, resulting in that 
irregular and spasmodic extrication of force which is recog- 
nized in all the protean forms of chorea. So prone are the 
motor centres to be affected in early life, that even when the 
mind is upset, and genuine insanity is recognizable, it is most 
frequently accompanied by noisy and violent action. Irreg- 
ular movements or cataleptic rigidity, with more or less of 
a choreic tendency, are constantly to be seen ; in fact, the 
insanity is more often shown in violence and powerful de- 
monstrations of emotional activity than in delusions and dis- 
order of the general intellect. Here, then, is a pathological 
condition to be marked off from others — a nervous tempera- 
ment undergoing the change which accompanies puberty, 
and unstable in consequence — upset, it may be, by some 
mental shock or debilitating illness, and characterized by 
disturbance of both mind and body, generally of a violent 
and spasmodic character. 

Let us look at the obverse of this, at the insanity which is 
b. insanity so frequently seen at what has been termed the cli- 

of the cli- . . . „ , 

macteric. mactenc period of life, at the time of the " change 



THE PATHOLOGY OF INSANITY. 71 

of life" in women, and at an analogous period, from the 
age of fifty to sixty years, in men. Here, as in early life, 
women break down more frequently, for the trial and the 
change is greater in them, and fraught with greater peril. 
But now we do not find noisy mania with great motility. 
Old age is approaching, when strength is but labor and sor- 
row, when the fading fires of life bring less supply to the 
centres, and so melancholia is the rule, mania the exception. 
It is to be noted that melancholia is exhibited at this period 
rather than in more advanced age, when dementia and decay 
mark a worn-out rather than a disordered brain. From the 
melancholy there is a way of escape, but the dementia will 
slowly and surely advance to absolute extinction of mental 
power. 

Again, we may observe an assemblage of pathological con- 
ditions making up the unit of disease exhibited in the patient. 
He may have inherited an unstable nervous nature, so the 
first cause or condition is hereditary taint, and this may or 
may not have already shown itself in previous attacks. The 
next condition is age. He or she has come to a time of life 
when the bodily organization is undergoing a change, and 
when the nerve centres are apt to become irregular in action. 
There may be superadded some loss or anxiety, or some 
lowering disorder, the supply of nerve energy is diminished, 
and melancholia is the result in the majority of cases. Where 
it does not amount to melancholia, the disorder is generally 
monomania, with suspicion and dislike, equally indicating a 
lowered self- tone. Occasionally we see merely an alteration 
of character, or the commencement of an incurable habit of 
drinking, and a gradual approach of that which begins as 
moral insanity and ends as hopeless dementia. 

Let us now consider the pathology of another group of 
cases where insanity shows itself during pregnancy c . Pue ,-perai 
or after labor. When we see the thousands of women insanit >- 
who go through these periods with perfect immunity from all 



72 THE PATHOLOGY OF INSANITY. 

such symptoms, it is clear that the pregnant or parturient 
condition is only one of a number of causes which must be 
sought and investigated. It must be connected with the 
insanity by means of a series of links which are often very 
hard to find. As I suppose not one woman in a thousand 
becomes insane after her confinement, we must search among 
the so-called predisposing causes for some reason of the mind- 
disorder in those who thus break down, and we must very 
closely investigate the physical symptoms at the time the 
mental first appear. Those of you who will attend cases of 
midwifery will see such symptoms at an earlier period than 
I do, and you may be able then to arrest them. In insanity, 
as in so many other diseases, prevention is better than cure, 
and it is to this that modern science must direct its efforts. 
The necessity for strict examination of the whole of the 
conditions at the first commencement of the mental symp- 
toms is shown when we see that the latter appear at very 
various periods. They may be first noticed during labor, 
immediately after, within a week, within the month, in two 
months, six months — in fact, at almost any period within a 
twelvemonth. After this we should not attribute them to 
the confinement; at any rate it would be a much more re- 
mote cause. They may appear in or after a perfectly easy 
and natural labor, or after one very difficult, and attended, 
possibly, with great exhaustion or hemorrhage. They may 
come on during lactation, or in a woman who has not suckled 
at all, or has long ceased to do so. When they make their 
appearance soon after labor, their approach is usually rapid 
and accompanied by acute symptoms, pain in the head, and 
sleeplessness. Here we notice that there is an accelerated 
rate of brain metamorphosis, not depending, as in the cases 
mentioned at the beginning of this lecture, on mental causes, 
on shock or the like, but on purely physical conditions. Now, 
we may observe that the nearer the first development of 
symptoms is to the time of delivery, the more violent and 



THE PATHOLOGY OF INSANITY. 73 

acute they are. Those which come on in the course of a 
week or fortnight are almost always attended with violence, 
sleeplessness, and great excitement, amounting to mania, 
whether the tendency is suicidal or not. Before delivery, or 
at a longer subsequent interval, the form is commonly melan- 
cholia or quiet monomania. This is accounted for by such 
theories as excitement from exhaustion, from the exhausting 
effects of labor ; but frequently insanity makes its appear- 
ance in cases where delivery has been rapid, no exhaustion 
has taken place, or when the exhausting effects must have 
passed away, some weeks or months having elapsed before 
any symptoms are seen. Other disorders occur at the time 
of parturition : there may be convulsions or paralysis, and 
not very unfrequently death occurs from embolism of the 
pulmonary artery. In all these cases w r e may infer that 
alterations in the brain have taken place, producing various 
manifestations of deficient nervous power. The normal mo- 
lecular changes are arrested and perverted by the distant irri- 
tation, or the arterial current is diminished through constric- 
tion of the vessels, brought about by disturbance of the 
vaso-motor centres, propagated by " sympathy" from the 
womb or its dependent parts, as the mammary glands. We 
know how mental causes may affect the lacteal secretion, 
and therefore the converse may be expected, that the cere- 
bral organs maybe disturbed by sympathetic "irritation" 
propagated thence. 

There are various disorders, known as nymphomania, sa- 
tyriasis, hysterical mania, and the like, which also rf N ym P ho- 
point to a connection between the insanity and the mania - 
sexual organs. That such a connection exists needs no demon- 
stration ; everyday experience shows it, but shows that these 
organs are affected from the head downwards quite as often 
as the reverse, e. g., the sight or smell of the female excites 
the male and the male organs hitherto quiescent. And when 
we see violent sexual excitement in the insane, we must not 



74 THE PATHOLOGY OF INSANITY. 

always assume that the origin is in the sexual organs, for I 
am convinced that it may be propagated from the excited 
brain to them. Here we must search through the analogies 
of other diseases and the teachings of pathology in general, 
and not be led away by a nomenclature into a rash conclu- 
sion drawn from phenomena which but too readily present 
themselves. It is extremely common to find in recent cases 
of insanity, where the patient is debilitated and out of health, 
that the catamenia are altogether absent, and the cessation 
accordingly is returned as the "cause " of the insanity. When 
the patient is recovering, and bodily and mental health re- 
turning, the catamenia reappear, and are said to have " cured" 
the brain disorder. But the absence of the function is quite 
as likely to be the concomitant as the cause of the mental 
symptoms, and we may be drawn away from the true pa- 
thology by fixing our attention too much upon it. If we 
look at the general constitution and the past history of any 
one of these patients, what do we learn ? That she has 
always been what is popularly called nervous or hj^sterical, 
prone to emotional display, to bursts of temper, to hysterical 
crying, exaggerated, it may be, at the menstrual period. 
Most likely other members of the family are nervous, pos- 
sibly some are insane. Thus is the old story repeated, — he- 
reditary predisposition to nervous disorder, a proneness to 
be upset by trifling occurrences, an unstable cerebral condi- 
tion, greatly influenced by sympathetic disturbance of the 
sexual organs and functions, and reacting in turn upon and 
violently exciting them. At first all these disturbances are 
for the most part temporary, very variable, perhaps periodical ; 
later, they may become fixed and incurable. 

Insanity in patients who have indulged largely in sexual 
e. insanity of excess or masturbation does not necessarily come 
masturbation. un( } er ^he last head, though masturbation may be, 
and constantly is, practiced by nymphomaniacal and hyster- 
ical women. Insanity accompanied by masturbation is a 



THE PATHOLOGY OF INSANITY. 75 

different thing from insanity caused thereby — different in its 
oncoming, different in its coarse and character, and rendering 
different the prognosis to be made concerning it. Insanity 
caused by masturbation is, generally speaking, gradual in its 
approach, not attended with any sudden or acute symptoms, 
but manifested in unpleasant conceit and exalted self-feeling, 
with delusions in accordance ; this gradually increases, nor 
is there any great hope of cure, for the brain seems to have 
undergone permanent damage from the constant irritation to 
which it has been exposed by the practice of the habit. 
Such a state of things altogether differs from the violent, but 
often transient, outbursts of hysterical or nymphomaniacal 
insanity, which are by no means incurable ; and it points to 
a different pathological condition. In the one we have brain 
disturbance coming on suddenly, possibly from some sympa- 
thetic uterine or ovarian irritation, which causes great dis- 
order of the cerebral circulation, and an acute attack of in- 
sanity, from which the patient may recover. In the other, 
first the brain is gradually altered and impaired by the un- 
ceasing demands made upon it, and the constant excitation 
caused by the act of masturbation. We may compare the 
latter, though less in degree, to frequently-renewed attacks 
of epilepsy or of alcoholic intoxication, which produce mental 
disorder by their constant recurrence through a series of 
years. 

The insanity which masturbation produces is for the most 
part seen in young persons, but there is another form found 
in those of middle age, the result of sexual excess or mastur- 
bation, which is known under the name of general paralysis. 
I shall hereafter describe this at length. Suffice it to say, 
that I believe the chief cause is sexual excess, whether in 
married or single life. Like the insanity produced in the 
young by masturbation, it is characterized by intense self- 
exaltation, by ideas of grandeur and importance, and a feeling 
of the most perfect health and strength ; and it would seem 



76 THE PATHOLOGY OF INSANITY. 

to be lighted up in the first instance by the constant irritation 
to which the brain is exposed by the frequent repetition of 
the sexual act. We see other effects of sexual excess every 
day in ordinary practice, such as lassitude, dyspepsia, giddi- 
ness, dimness of sight. These are the results of expenditure 
and exhaustion of nerve power ; but here, if the cause is re- 
moved, the effect ceases, and the patient recovers. Once, 
however, the insanity called general paralysis is set going, 
there is at present no cure for it known. This, of course, 
points to a pathological condition entirely differing from that 
of any curable or transient form of insanity. 

As in some mere nervous exhaustion and bodily disorder 
are produced by masturbation and sexual excess, while in 
others genuine insanity is the result, so. other causes, as 
epilepsy and alcohol, give rise to insanity in some, to decay 
of mind and body in others. The original constitution and 
pathological condition of the individuals being different, the 
result is different, though the cause is the same. We find in 
practice that patients in various ways, and through various 
stages, arrive at legal unsoundness of mind. In the eye of 
the law they are all alike, all incapable of taking care of 
themselves or their affairs ; but to the pathologist they pre- 
sent infinite diversities, and the points of difference will be 
multiplied more and more as our means of scientific research 
are extended. 

Let us take the various pathological conditions produced 
4. insanity by alcohol : there can be no better illustration of 
of aicohoi. w } ia | : j have just said. First of all, a man may be 
drunk, paralyzed in speech and ideas by alcohol, furious with 
drink, or wholly insensible. Another may suffer from de- 
lirium tremens^ even after he has ceased drinking, perhaps 
for days. Besides these, we may notice a third state : in- 
stead of delirium tremens, which runs its course in a week 
or so to recovery or death, an attack of ordinary insanity 
with delusions may come on in a person accustomed to drink. 



THE PATHOLOGY OF INSANITY. 77 

From this he may recover after a considerable period. And, 
besides, the habitual drinker, man or woman, may lapse into 
dementia, into utter obliteration of memory and mental 
power, into premature old age, from which he never will 
emerge again. In each of these states there is for the time 
unsoundness of mind from drink, but how great is the differ- 
ence in the pathology of them ! In the man who is drunk 
we see the effect of the alcohol circulating in the a . Drunken - 
blood, and conveyed in it to the brain-cells and ness - 
fibres ; in fact, to the whole nervous system ; mind centres 
and motor centres, afferent and efferent fibres, are all affected, 
and their functions more and more impaired, till absolute 
insensibility and paralysis, nay death itself, ensue. Can we 
say which of our nerve organs are implicated in these vari- 
ous states ? In intoxication, as I have said, all seem affected. 
There is a disordered cerebral circulation, after even a mod- 
erate amount of wine or spirits, shown in flushing of the face 
and excitement in talking and manner. Yery soon the move- 
ments of the tongue and lips are affected. There is some 
loss of control. The words are somewhat clipped, are not 
enunciated in a measured and even manner. This may 
occur in some before there is any confusion or impairment 
of mind, and appears due to an affection of the motor centres 
or fibres, or of the commissures which co-ordinate and focus 
the .movements. I hold that these phenomena are due to the 
presence of alcohol, and not to mere alteration in the blood 
supply of the part, because we notice them in some who are 
very drowsy after taking wine — and by drowsy I do not mean 
comatose from drink — while others who are noisy and talk- 
ative exhibit the same. The mental symptoms correspond 
to the motor. There is at first a want of co-ordination of 
thought, an inability to recall just what is wanted at the 
moment, and this after a very small amount of wine; and 
yet there may be an entire absence of excitement, or any- 
thing denoting any great difference in the cerebral circula- 



78 THE PATHOLOGY OF INSANITY. 

tion. The presence of the alcohol, then, in the blood is the 
main pathological fact in this condition. When this is elim- 
inated, the man is well again ; but if it be present in large 
quantity he will die, and the experiments of Dr. Anstie on 
animals show that the mode of death is paralysis. The 
good effects of a glass of wine are possibly due to an in- 
creased circulation, brought about by the influence exercised 
over the vaso-motor system. When a man is intensely 
sleepy after taking strong drink, it would seem that his brain 
is deadened to ordinary stimuli. Owing to impure blood, all 
changes therein cease, as in narcotization from chloroform, 
only violent shaking or shouting can then rouse him. 

But in delirium tremens we have a widely different state 
b. Delirium of things. This is but little removed pathologi- 
tremens. cally from the acute delirium of the insane, though 
it is shorter in duration. It is not the actual presence 
of alcohol which causes the symptoms, for none may have 
been taken for days, so that it is often asserted that the 
withdrawal of drink is the cause, and we are told that we 
must not fail to give the accustomed stimulus when treating 
the disease. The truth, however, seems to be that by con- 
stant drinking — and, I may add, by loss of food, wdiich is 
almost always the concomitant — the nerve centres are re- 
duced to so unstable a condition, that the slightest thing, an 
accident, or grief, or anxiety, or any mental shock, upsets 
the balance ; and then ensues that indication of a lack of 
power exhibited by muscular tremor, together with that 
incessant talking, sleeplessness, and mental disturbance, 
with which you are so familiar, denoting rapid molecular 
decomposition in the brain centres. We may see nearly the 
same attack in patients brought to a like unstable condition 
by exhaustion or want of food. But we shall not in these 
see the peculiar muscular tremor, though there may be con- 
vulsive or cataleptic phenomena of other kinds. 

In delirium tremens it is evident that there is a disturb- 



THE PATHOLOGY OF INSANITY. 79 

ance of the brain to such an extent, that unless it subsides 
the patient is liable to die of exhaustion of his nervous 
power, which has no chance of renewal. Modern research 
has not yet enabled us to lay down with precision the patho- 
logical state of the brain in this disorder. Though the want 
of sleep, the exalted temperature, and rapid pulse, point to 
an accelerated molecular change, yet many facts lead us to 
suppose that delirium is the result of a defect of the normal 
blood supply. And we are, in my opinion, driven to the 
belief that a combination of these states exists in the violent 
delirium called delirium tremens, as well as in the delirium of 
acute mania ; that the accelerated blood-flow which at first 
is manifested in sleeplessness, excitement, and incoherence 
of thought, may increase to a point when, instead of a rush 
of blood, there is a stagnation, at any rate in certain por- 
tions, and then wild delirium at once sets in. 

Not rarely does insanity, mania, or melancholia, make its 
appearance in people who have for years led lives of c> i nsauity 
intemperance. Here we meet with a somewhat dif- fromdrink - 
ferent pathological condition. There may never have been 
an attack of delirium tremens. The patients either have 
not taken enough, or they have escaped the accidents which 
lead up to it, or their constitution does not expose them to 
this particular form of disorder. So, instead of the busy 
wakeful delirium and incoherent wandering, we find the 
delusions and outrageous acts of ordinary insanity. Patients 
recover from these attacks, return to intemperate habits, 
break down again, and may recover again and again, but, 
rarely giving up drinking, they for the most part die in con- 
firmed insanity. A few consent to remain under some sort 
of control or surveillance, and so escape. If we consider the 
probable pathology, we must conclude that the repeated 
states of intoxication, like constantly renewed anxiety or 
incessant labor of brain, bring about in time an irregularity 
of circulation and of function, a certain instability and de- 



80 THE PATHOLOGY OF INSANITY. 

feet which do not amount to delirium, but may be manifested 
in delusion and violent and maniacal conduct, with irregular 
and imperfect sleep. Abstinence, however, and the quiet of 
a life under control, may enable the brain to recover its 
balance ; but I have known two years elapse before the cure 
was effected. 

There is one more pathological state connected with the 
d. imbecmty habitual use of alcohol. After years of habitual 
from drink, drinking, drinking which may hardly have amounted 
to intoxication, far less to delirium tremens, we may perceive 
the mind weakening, memory failing, and the dotage of prem- 
ature old age coming on ; and not unfrequently with this 
decrepitude of mental power, we notice some amount of bodily 
paralysis, which slowly advances at the same time. This is 
the manner in which women often show the effect of drink, 
and for them there is no hope. We may reasonably infer 
that, from the long-continued poisoning, irritation, or what- 
ever we like to call it, the nerve centres and nerve cells and 
fibres are degenerate, and have lost their structural perfection 
and efficiency. These cases are very curious and interesting 
to watch. Quite suddenly, without illness, sleeplessness, or 
excitement, memory gives way. The . patient talks quite 
rationally and calmly, but does not distinguish yesterday 
from last week, thinks friends long dead are alive, and when 
set right, makes the same mistake Hvq minutes afterwards. 

Here is commencing dementia, a pathological condition re- 
sulting from many antecedent events, of which drinking is 
one. I have known patients recover to a considerable extent, 
but in all there was left some amount of weakness, mental or 
bodily. They did not regain their former state as a man 
does after delirium tremens. 

There are some substances besides alcohol which, by con- 
stant use, may bring about insanity. Notably, this 
from other is the effect of bhang, or Indian hemp, which sends 
many patients to asylums in India, producing a form 



THE PATHOLOGY OF INSANITY. 81 

of excitable mania with delusions, from which they for the 
most part recover. You will not meet with these cases in 
our own country, but in certain parts of the East they are 
common. In Europe there is a preparation of absinthium; 
which is also said to produce mental symptoms, if largely 
taken. There is much controversy, however, concerning it, 
many asserting that the harm done by absinthe depends on 
the alcohol taken, and not on any peculiar properties of the 
herb. I am not aware that any but an alcoholic preparation 
is ever drunk, so that it is difficult to come to any decision 
on the subject. That opium produces curious phenomena 
and trains of ideas out of the control of the will, may, I think, 
be admitted by all. I cannot say, however, that in my ex- 
perience it has been often found to produce insanity. The 
anomalous symptoms are due to the actual presence of opium, 
to a poisoning going on at the time ; but if it is withdrawn, 
these vanish. The brain and nervous system are affected, as 
are those of a man breathing nitrous acid gas ; but when the 
cause is removed, the effect ceases, and the pathological con- 
dition is not one which deserves the name of insanity, any 
more than that of a man who is drunk with alcohol, or de- 
lirious under the influence of chloroform or nitrous oxide. 
Practically, we do not find that opium eating or smoking 
swells the population of the lunatic asylums of this or other 
countries. There is an immense difference between the re- 
sults of the continual use of opium and, alcohol. Dr. Chris- 
tison even thinks that opium-eating does not necessarily 
shorten life. Certain it is, that our two most noted opium- 
eaters, De Quincey and S. T. Coleridge, lived, the former to 
the age of seventy-four, the latter to that of sixty-one years. 
Turn we now to a different pathological state, to that of a 
patient in whom insanity has appeared consequent 6 insanity 
upon a blow on the head. So numerous are the cere- afterablow - 
bral symptoms which, at varying intervals, follow blows, that 
it can cause no surprise if among these we occasionally meet 

6 



82 THE PATHOLOGY OF INSANITY. 

with insanity. Imbecility, paralysis of limbs, a gradually 
advancing decay of mental and bodily power, is perhaps a 
more frequent sequel than insanity, strictly so called, yet this 
is to be found. When after a blow a man or a woman de- 
velops insanity in the form of mania or melancholia, or gradu- 
ally becomes altered in character, or subject to fixed delusions, 
we may conclude that the injury the brain has undergone is 
not of the coarse character described in works on surgery. 
There is no traumatic inflammation of the brain-substance, 
or the membranes, such as we are accustomed to see in the 
post-mortem theatre of our hospitals. We have to deal with 
a much more minute and molecular change — a change com- 
mencing, it may be, in the contusion of the gray matter 
caused by a blow or fall, and producing an alteration in the 
nourishment and growth of the part, in the blood supply, or 
in the nerves presiding over it. That condition which I have 
vaguely called instability of nerve function and force may be 
in this manner set up, as it comes to others by inheritance ; 
and so it frequently happens that men who have received 
blows on the head are driven to a state of frenzy or mania 
by slight causes, which would produce little or no effect on 
an uninjured and healthy brain, such as a very small amount 
of drink, or trivial matters exciting anger or grief. From 
such transient attacks patients recover, and return to their 
normal state of equipoise, to be thrown off their balance again 
by some other disturbing event. But when the change in 
the mind is insidious and gradual, when acute symptoms are 
absent, and either quiet and concealed delusions, or a mere 
perversion and alteration of the whole man are alone to be 
noticed, our prognosis must be extremely unfavorable, if we 
hear a history of a blow or fall on the head. 

There is yet another pathological condition brought about 
by a cause external to the individual. This is the insanity 
developed in people, chiefly men, who have been long ex- 
posed to the heat of the tropics, whether they have had an 



THE PATHOLOGY OF INSANITY. 83 

actual sunstroke or not. Even here in exceptionally hot 
summers, such as that of 1868, not a few cases are 

7 % 7. Insanity 

directly attributable to this cause; and in my own ex- after ex P o- 
penence I have met with a large number ol patients 
who, either in India, or on returning thence, have shown 
symptoms of insanity. Of course, when we say that heat 
causes insanity, we are speaking of patients who have been 
subjected to a degree of heat to which they are unaccus- 
tomed, and which by their race and constitution they are 
little fitted to endure. I am not now comparing the natives 
of tropical countries with those of colder regions. The 
former lead for the most part simple lives, and are temperate 
as regards the use of alcoholic drink. The dwellers in cold 
climates, as Sweden and Norway, are notoriously intemper- 
ate, and we have seen already how large a part this habit 
plays in the causation of insanity. Here, as in so many 
other conditions, we shall find that the man who is by in- 
herited nature of an unstable nerve organization will suc- 
cumb to the influences of climate, particularly if, in addition 
to these two causes, he combines the effect of intemperate 
habits, or of exhaustion produced by mental anxiety or bodily 
illness. 



LECTURE IV. 

The Pathology of Insanity, continued — Senile Insanity — General Pa- 
ralysis — Insanity in Acute Diseases — Recurrent Insanity — Idiopathic 
Insanity — Insanity with Epilepsy — Insanit3 T with Rheumatism — With 
Syphilis — With other Neuroses — With Diseases of. the Head, Liver, 
Heart, Kidneys, Stomach — Insanity with Tuberculosis — With Pe- 
ripheral Irritation — Do the Mental Symptoms correspond with the 
Pathological variety ? — What is the Pathology of Insanity ? 

There are patients who go through life as sane men, and 
8. senile break down and become insane when they have grown 
insanity. Q ^ no j. a |. t j ie c ii mac teric period, but when old age 
has finally begun. Although we call this senile demen- 
tia, and set it down as dotage, second childhood, the com- 
mencement of a decay which is to spread over mind and 
body, yet we may notice at the beginning many of the 
symptoms of insanity. There may be at first mental altera- 
tion rather than alienation — that alteration of character, 
habits, conduct, and affections, which, existing without delu- 
sions, has been called moral or emotional insanity. Or 
delusions may exist with acute symptoms, violence, and 
sleeplessness. We cannot but conclude here that the age, 
and the decay or want of vigor in the various organs con- 
cerned in mind, guide us to the pathological state, and indi- 
cate that changes, both structural and functional, have com- 
menced. When we see the numberless cases of old people 
in which after death an atrophied condition of brain is found, 
we can understand how the defect of circulation or of nutri- 
tive blood, which has led in some people to simple atrophy, 
may cause in others more marked mental disturbance, result- 
ing in positive insanity rather than in the negation of mind 



THE PATHOLOGY OF INSANITY. 85 

termed dementia. That the one will merge into the other 
may reasonably be expected. We are not to hope for a cure 
of either, but as pathologists we may draw a distinction be- 
tween senile insanity and senile dementia. 

I may mention in this place, though I shall not now dis- 
cuss it at length, that special form of insanity which General 
is called general, or progressive paralysis of the insane, paralysis of 

-...-. ,, .,. the insane. 

which I have already incidentally noticed in speak- 
ing of the insanity of masturbation. Here, beyond question, 
we have a disease well defined, recognizable, fatal to life, and 
running a rapid course, little influenced by care or treatment. 
The pathological conditions of this must needs be different 
from those of mental disorder lasting for the term of a life. 
There are various conditions which are quite peculiar to it. 
It is far more common in men than in women. It rarely, if 
ever, attacks people under the age of twenty or over sixty. 
Generally, we may say that it attacks men in the prime of 
life. Now, what is the causation of this disorder? I myself 
am strongly of opinion that in a large majority of cases 
sexual excess, either venery or masturbation, is the chief 
excitant of this fatal form of insanity. Then, what is the 
seat of it? We might surely expect that there would be no 
difficulty in determining the seat of a malady which destroys 
life in a year or two. But pathologists are not agreed on 
this point. One, at least, has tried to prove that the seat is 
in the spinal cord ; and though this is not consistent with 
the mental symptoms and the affection of speech, yet if my 
theory of the origin being sexual excess is correct, we may 
expect to find that the spinal cord is involved, and even that 
disease of the latter precedes in some cases that of the brain. 
The peculiarity is that this form is progressive — that, even 
if we have remissions and apparent recoveries, the latter are 
not real, the damage already done is not thoroughly repaired, 
and after a brief interval the symptoms return in greater 
force, and advance gradually though surely to extinction of 



86 THE PATHOLOGY OF INSANITY. 

life. All these topics must be discussed at length hereafter. 
At present it suffices to place general paralysis apart as a 
special pathological variety, having affinities with the other 
forms of insanity, but distinct from them. 

I know not whether I ought to speak of recurrent insan- 
necurrent ity as a pathological variety. All insanity is apt to 
insanity. recur? an d to assume different forms at different 
times. But it sometimes happens that it recurs with such 
regularity as to constitute a marked and characteristic dis- 
order, which for purposes of prognosis and treatment has to 
be considered apart. We may watch a man or a woman 
pass through an attack of, perhaps, acute mania. Gradually 
reason returns, the symptoms subside, and the patient goes 
on to convalescence without a single drawback; but just as 
we think that he may safely be freed from control, suddenly, 
perhaps in a few hours, the whole thing begins again, and 
he goes through the same stages, again to recover and again 
to relapse. This may go on for years, the intervals varying 
according to circumstances and surroundings ; the attacks 
also differing in severity, but the disorder remaining un- 
cured, and never losing its recurrent character, even when 
dementia has taken the place of a return to a state of sanity. 
These intervals vary from weeks to years. I formerly had 
under my care a man of more than eighty years, whose 
first attack happened when he was seventeen, and who, 
in the interval, had been put into confinement three-and- 
thirty times. I know another gentleman who breaks down 
every two years or thereabouts; but in many the attacks 
follow one another with so short an interval that they re- 
main permanent inmates of asjdums. Could we accurately 
define the condition of such patients, we should have solved 
the pathology of insanity. They seem to be the very crux 
of the whole matter, for we cannot, as a rule, assign any 
cause for the recurrence. The disorder once set up in the 
individual's constitution is prone to recur, and we must 



THE PATHOLOGY OF INSANITY. 87 

examine the whole question of the periodicity of disease, 
as well as the conditions of the first attack, before we can 
hope to throw any light on the subject. This much we may 
conclude, that the conditions which precede the first, are not 
necessary to subsequent attacks; that as epileptic seizures 
may continue after the ostensible cause of the first fit is re- 
moved, e. </., worms, so the disorder once recurring may repeat 
itself, persistently remaining as a vice of the constitution of 
the individual, of which it now forms a portion. We know 
that there is a periodical rise and fall in almost all diseases — 
a time of day at which fever-patients are worse or better, a 
time of year at which other disorders recur — and we may 
compare with this the periodical season of sleep, of fecunda- 
tion, of nutrition, and such like normal functions of the 
animal organism. These cases of recurrent insanity may 
present the phenomena of attacks of mania, alternating with 
recovery, or of melancholia, also alternating with recovery, 
but besides, mania may alternate with melancholia, consti- 
tuting what the French ca\\ folie circrdaire, or folie a double 
forme. The one may succeed the other immediately, or there 
may be between them a period of convalescence and sanity, 
such as is called by lawyers a "lucid interval." This has 
been described as a special form of insanity ; it is, however, 
but a variety of that which I have termed recurrent insanity, 
with an alternation in the emotional condition of the patient. 
I now come to a class of cases which I do not myself hold 
to be a pathological variety, but which I mention I(liopathic 
because it is so arranged by some writers for whose insanit >- 
opinion I have the utmost respect. This is the form which 
has been described as idiopathic insanity, whereby is meant 
that it cannot be brought under any one of the heads already 
mentioned, and no cause for it can be assigned. In the ma- 
jority of the certificates brought with patients to asylums 
the cause of the insanity is returned as unknown, and fre- 
quently this may be the truth. In a great number of cases, 



88 THE PATHOLOGY OF INSANITY. 

however, we should more truly say that the patient is insane 
because his father, or mother, or grandfather, or grandmother 
was insane before him. Idiopathic insanity is that which 
makes its appearance in an individual without assignable 
cause, simply because by his inherited nature he has a tend- 
ency to become insane. But we must still ask the question, 
What is his pathological condition at the time the insanity 
is first manifested ? In what does he differ from sane brothers 
and sisters, all offspring of the same parents ? As the symp- 
toms of this insanity differ in no respect from that which is 
brought about by other conditions, moral or physical, we can 
only say that the patient, through an inherited tendency to 
disturbance of his nerve centres, or through a disturbance 
engendered in them by an assemblage of conditions so 
obscure that we cannot demonstrate them, has arrived at the 
same state pathologically as others who through grief, or 
work, or parturition, or drink, have developed insanity. 
Whatever be the assemblage of conditions giving rise to an 
attack of mania or melancholia, it is probable that the 
pathological condition of the patients at the time is very 
nearly the same, and so we find that with little variety in 
the treatment a large majority of cases recover merely by 
being kept in rest and safety during a certain period of time; 
and we also find that patients recovered, though not in the 
same proportions, in former ages, when detention was all the 
benefit which they received, the treatment, when there was 
any, being of very questionable utility. 

The remaining pathological conditions which I shall briefly 
review are all of them combinations of bodily diseases, such 
as may exist alone, and mental disturbance, giving rise to 
that which we call insanity. The latter may present itself in 
patients who are the victims of chronic diseases, as phthisis, 
syphilis, or rheumatism. It may coexist with disease of the 
heart, liver, or kidneys. It may accompany epilepsy, or 
come on quite suddenly in the course of acute disorders, 



THE PATHOLOGY OF INSANITY. 89 

measles, pneumonia, fevers, and the like. The consideration 
of all these conditions involves some most obscure and intri- 
cate questions of pathology; but I think that a careful 
examination of the phenomena throws some light on the 
nature of the disorder of the brain. In all these it is clear 
that we have a combination of conditions making up one 
pathological whole. As thousands of patients suffer from 
the above-mentioned diseases without any signs of insanity, 
we must look for other concomitant causes besides those I 
have mentioned. 

The first class of such cases of which I shall speak is that 

of insanity occurring in the course or at the decline 

n -i • -i a -I i i it 10 - Insanit y 

oi acute disorders. And here, to shorten what 1 in acute 

have to say, I may direct you to an interesting paper 
on the subject by Dr. Hermann Weber, in the 48th volume 
of the " Medico-Chirurgical Transactions." In this he gives 
the particulars of seven cases of measles, scarlatina, ery- 
sipelas, pneumonia, and typhoid fever, where, towards the 
decline of the disorder, maniacal delirium came on, with 
delusions of an anxious nature, and hallucinations of the 
senses, especially of hearing, but also of sight. The duration 
of the derangement was short, extending from less than 
eight to forty-eight hours. The outbreak was sudden, the 
time was in general the early morning. Almost ahvays the 
commencement teas stated to have occurred immediately after 
wale ing. 

These cases are called b}~ Dr. Weber the " delirium of 
collapse" — a name, however, which throws but little light 
on their pathology. The points to be borne in mind are the 
transitory nature of the attack, its sudden oncoming, especi- 
ally on waking from sleep, and the partial nature of the 
delirium, this taking the form of delusions, and not being 
the general incoherent wandering of the ordinary delirium 
of fever. We may suppose that the combination of condi- 
tions is something of this kind. First, the patient is by 



90 THE PATHOLOGY OF INSANITY. 

inheritance "excitable;" his nerve-balance is easily upset. 
" Excitable." a naturally anxious and excitable," " over- 
conscientious," are terms applied by Dr. Weber to several 
of his patients. By the acute disorder and the accompany- 
ing fever, the temperature has been considerably raised, and 
the circulation necessarily disturbed. During the heightened 
temperature, Dr. Weber tells us, there was no delirium ; but 
the circulation and temperature fall, less blood is carried to 
the exhausted brain centres, sleep comes on when the brain 
circulation is even more reduced, and then on waking sud- 
denly from a short sleep delusions more or less of a melan- 
cholic or anxious character manifest themselves ; food and 
opiates procure a long sleep, and the brain circulation having 
regained its normal condition, the delusions vanish. The 
sudden outbreak of insanity on waking from a short sleep is 
familiar to all who have the care of the insane. In acute 
mania, patients who sleep half an hour, or an hour, often 
wake in a furious paroxysm. Many a crime is committed 
by others subject to transient attacks of insanity, when they 
are just awakened from an insufficient sleep. Suddenly to 
wake even a sleeping dog is a thing which most look upon 
as attended with risk. It is a matter of common observa- 
tion that melancholic patients, who especially manifest a 
lack of force, are almost invariably more dejected at first 
waking ; and I have known a lady, who was in no sense 
insane, habitually depressed to an extreme degree when she 
first woke, the feeling passing away as the circulation was 
restored by exercise. 

After these cases, I may proceed to the consideration of 
11. insanity insanity caused by epilepsy. As we saw that there 
with epilepsy. was a f orm f insanity, as well as imbecility and 
chronic dementia, brought about by alcohol, so after an 
epileptic attack, or series of attacks, we may have a transient 
outburst of delirium, or an invasion of insanity with delu- 
sions, lasting from days to weeks, and then passing off, and 



THE PATHOLOGY OF INSANITY. 91 

leaving the patient sound in mind until a fresh seizure 
occurs. This is a condition quite distinct from the loss of 
memory and general dementia, which, if the fits are at all 
frequent, gradually encroaches upon the mind, and almost 
without exception terminates the career of every epileptic, 
even when there has been no insanity properly so called 
throughout the entire illness. Can we in any way account 
for an attack of delirium or of mania supervening in one 
person after epileptic attacks, while another comes out of 
them comparatively unscathed ? Here we must suppose 
that the disturbance of the brain circulation implied by the 
epileptic seizure does not at once subside as it does in a 
patient who in an hour appears to be in all respects sane and 
unchanged; the reaction, if we may so term it, after the fit 
or fits, brings about a great disturbance of the circulation, 
and, according to the degree thereof, symptoms of insanity 
may appear, varying from a moderate mania to wild and 
unconscious delirium. The more numerous the attacks the 
more likely is mania to supervene. I have known a patient 
who, after three or four fits, woke sane; but if they were 
more numerous, if he had twelve or thirteen, he was for 
days in a state of mania, with many hallucinations and 
delusions — a state which was not cured at once by a sleep, 
but which gradually subsided like an attack of ordinary 
insanity, and was, in fact, in all respects the counterpart of 
it. The point to notice is that so many patients suffer from 
epileptic fits without undergoing this general disturbance • 
though their brain circulation is so disordered that we see 
first the fit, and then possibly a prolonged condition of coma- 
tose sleep, yet here the disturbance terminates, and the 
sufferer wakes sane. 

The dementia attending upon chronic epilepsy is at any 
rate more easy to comprehend ; but we must not too hastily 
set this down to structural change, for it is marvellous how 
some patients, long lost in speechless idiocy, recover intel- 



92 THE PATHOLOGY OF INSANITY. 

ligence and power, if by some chance, or some medicine, the 
fits are arrested. Exhaustion of force is clearly here to be 
noticed. The constant fits prevent this From ever accumu- 
lating in adequate quantity; but, if they cease, it again 
shows its presence in the centres. For 1 take it that in the 
convulsions the force of the entire cerebral system is poured 
out in muscular movement. When the attack is but slight, 
then consciousness is not lost at all, or only for a moment. 

Passing from the combination of insanity and epilepsy, we 
12. insanity come to another, insanity and rheumatism or gout, 
withrheu- This is a commonly recognized complication, and we 

matism or ^ ° x ' 

gout. not unfrequently find stated in books, and observe in 

practice, that the symptoms of the one disorder vanish as 
those of the other appear, and vice versa. I myself have 
seen phenomena of very acute insanity disappear quite sud- 
denly, to be followed by great pain and swelling of hands or 
feet. This has been called metastatic insanity, and it has 
been supposed that the seat of the inflammation, caused by 
a blood poison, is transferred from the brain or its membranes 
to the joints. We may, at any rate, remark that there is a 
marked* analogy between the way that the acute symptoms 
of transient mania often entirely subside and vanish, and 
that in which we see the pain, heat, and redness of a joint 
disappear within a few hours, leaving nothing behind but 
some stiffness and tenderness as relics of what appeared 
most acute inflammation. It is not for me to tell you what 
is the exact pathology of acute rheumatism or of gout ; the 
differences of opinion which still exist among observers of 
these common maladies may at any rate be some set-off 
against the doubts and difficulties that beset me in trying 
to lay down as facts the pathological conditions of insanity. 
But when we see how the connective tissue is attacked by 
these disorders, how acute are the symptoms, and how rapid 
and complete their disappearance, we may suspect that the 
connective tissue of the brain may occasionally participate ; 



THE PATHOLOGY OF INSANITY. 93 

and as the vessels going to the gray substance are meshed 
in this, it may well be that the brain circulation is in this 
manner greatly disturbed. 

The connection between rheumatism and insanity, rheu- 
matism and chorea, and rheumatism and other head symp- 
toms, has been dwelt upon by many physicians — Griesinger, 
Trousseau, Sander, Hughlings Jackson — and a most interest- 
ing account of two cases, in which rheumatism, chorea, and 
insanity coexisted, is given by Dr. Clouston in the " Journal 
of Mental Science," July, 1870. Here the rheumatism was 
the first symptom. In one case, a woman aged twenty-four, 
the rheumatism existed for two months before the insanity. 
It suddenly abated, and mental and choreic symptoms com- 
menced. There was loss of power in all the limbs, the legs 
were quite paralyzed, and reflex action destroyed. The mind 
was in a state of stupor and depression. Recovery took place 
in about three months. The second patient, a lad of nine- 
teen, had already had chorea at the age of seven and thir- 
teen. After an acute attack of rheumatism of two weeks, 
choreic symptoms commenced, with strangeness of manner, 
restlessness, and inattention. His mind then became greatly 
confused, with hallucinations of vision, delusions, and occa- 
sionally refusal of food. Recovery took place in about three 
months. Dr. Clouston remarks, that the symptoms were 
very similar in both these cases ; in both the rheumatism 
was the commencement of the attack; in both there were 
choreic symptoms, paralysis of motor power, a deadening of 
the reflex action of the legs, similar mental phenomena, 
high temperature, increased at night, and a tendency to im- 
provement in all the symptoms coincident with the lowering 
of the temperature, showing that the same lesion existed in 
both. All this, he thinks, indicates " a serious but transitory 
interference with the functions of the nerve cells and fibres 
in the spinal cord, such as might be produced by slight rheu- 



94 THE PATHOLOGY OF INSANITY. 

matic inflammation, and infiltration of the connective tissue 
of the cord causing pressure on the nerve elements." 

Other cases which appear to constitute a pathological class 
i3. insanity are those in connection with syphilis. Probably, as 
with syphilis. i n q U i rers pur SU e their investigation of this form, we 
shall gain a clearer insight into the manner in which the 
constitutional poison affects the higher brain centres. There 
have been various observations published of late on disease 
caused remotely by syphilis, producing alterations in the 
walls of arteries, and other lesions. I have seen a woman 
whose insanity appeared to be unquestionably of syphilitic 
origin, and who had had symptoms of paralysis, such as 
ptosis, also looked upon as syphilitic, and treated as such. 
This woman was placed in an asylum, where she recovered 
perfectly. Here the pathological changes could not have 
advanced far, and may have consisted in alterations in the 
quality of the blood, or in the supplying vessels, of a nature 
which treatment removed. But such cases of recovery are 
not very common. Syphilitic insanity is usually spoken of 
as syphilitic dementia, which gradually progresses till life is 
extinguished in no long time. And the appearance found 
after death is described as syphiloma, or a gummy tumor 
found within the brain itself, or a diffuse fibrinous exudation 
between the membranes and the brain. The whole points 
to a condition I shall have to advert to again, in which the 
normal textures, the brain-cells, fibres, and vessels undergo 
a retrograde metamorphosis, and are invaded by, or converted 
into, lower forms of life, connective tissue, exudation cor- 
puscles, or albuminous products hardly organized at all. 

In speaking on the subject of hereditary transmission, I 
shall have occasion to point out to you that amongst 

14. Insanity # . 

with other the children of nervous or insane parents one may 
be hysterical, one hypochondriacal, a third a drunk- 
ard, a fourth epileptic, or a fifth insane. But you may also 
find two of these neuroses combined in one individual, or 



THE PATHOLOGY OF INSANITY. 95 

alternating in him or her. Thus hypochondria may drift 
into insanity, and, as the insanity passes off, the symptoms 
of hypochondria will again become prominent. So with 
hysteria. Besides the hysterical mania so often witnessed, 
insanity, mania, or melancholia may take the place of the 
former hysterical attacks. And it has often been remarked, 
and I myself have several times met with instances, that 
neuralgia may be followed by insanity, the pain vanishing 
during the mental disturbance, and reappearing as the latter 
passed away. In one case, neuralgia of the spine, for which 
a gentleman was kept to the sofa for some months, was fol- 
lowed by deep melancholia. In another, very acute mania 
followed neuralgic pain, which a young lady had endured 
for a long period. Sir B. Brodie narrates similar cases in 
his work on " Local Nervous Affections." Now, that hys- 
teria and hypochondria are mental affections is all but uni- 
versally acknowledged, and we merely see an alteration in 
the symptoms of the neurosis, depending upon some altered 
condition of the patient, just as mania alternates with mel- 
ancholia in the so-called folie circulaire. And in the transi- 
tion of a neuralgia we may well believe that the neurotic 
affection is merely changed from one nerve centre to another, 
from the centres of sensation to those of mind. The prog- 
nosis, so far as the passing away of the first attack of insanity 
is concerned, is favorable in all these cases, but the whole 
state of the patient is one of evil omen; for it is clear that 
the nervous system is highly unstable, and not likely to be 
free from disorder of some kind or other, while, as years go 
by, the form of this will probably be more and more serious 
and incurable. 

Insanity coexists not only with acute disorders, or such 
as epilepsy, syphilis, or rheumatism, but also with others, 
whether it be caused by them or not. We find it coexisting 
with diseases of the head, of the lungs, the heart, the liver, 
and kidneys. I must pass in review each of these organs, 



96 THE PATHOLOGY OF INSANITY. 

but this much may be said with reference to them all. In 
estimating the connection which exists between insanity and 
diseases of the above-mentioned organs, it is of no use to ex- 
amine the statistics of post mortem examinations conducted 
in large lunatic asylums, unless we tabulate the results in a 
manner much more precise than that usually met with. The 
commonest source of fallacy is this. A large number of the 
patients who die in asylums have been insane for years; it is 
therefore impossible to say whether the disease of lungs, 
heart, or liver, found after death, was, or was not, a patho- 
logical condition coexisting with the commencement of the 
insanity. When we discover tubercles in the lungs of a pa- 
tient who has for perhaps twenty years undergone confine- 
ment in an asylum, with all the concomitants and depression 
arising out of such a life, we may well believe that the lung 
disease is long subsequent to the insanity. When another 
patient has been for an equal time constantly subject to vio- 
lent excitement, we need not be surprised to find his heart 
in an altered state. 

Let us first take the head : if you examine the records of 
the post-mortem examinations made in any large 

15. Insanity L , • i i i 

with diseases asylum, you will probably be struck with the ab- 

of the head. n t j i i /v» • , i 

sence 01 disease in the brain sumcient to account 
for death : and if you compare them with the case-books, 
you will learn that patients die comatose after the exhaus- 
tion of acute mania, or sink from exhaustion without coma, 
or die of apncea or syncope, but will comparatively seldom 
find the diseases of the brain met with in the post-mortem 
theatres of our general hospitals, such as tumor, abscess, 
hydatids, inflammation of an acute character of the brain 
or membranes, or tubercular meningitis. From the latter 
causes unsoundness of mind m&y undoubtedly spring, and 
legally we may have to deal with patients brought by one 
of them to this condition, but they chiefly produce feeble- 
ness of intellect, and wandering and dementia, or delirium 



THE PATHOLOGY OF INSANITY. 97 

or coma, such as you see in the wards here, and not insanity 
proper, such as I am more especially speaking of, which is 
treated in special asylums and institutions for the insane. 
Nevertheless, the presence of a tumor in any part within 
the cranial cavity may give rise to insanity, and in our 
autopsies of the insane we occasionally find such. We must 
conjecture that the derangement is caused by the sympathetic 
irritation of such foreign bodies rather than by their actual 
invasion of the parts concerned in mental operations. When 
the latter happens, we should expect dulness and imbecility, 
not insanity. We may also conjecture that in a patient in 
whom insanity is caused by a tumor, other pathological 
conditions exist favorable to the development; thus, of a 
woman who died at St. Luke's Hospital, in whose right cere 
bral hemisphere was found a tumor of the size of a pullet's 
egg, it is recorded that her sister was insane. In this case 
mania existed for two months, but before death there were 
noticed drowsiness, ptosis of the left eyelid, and loss of 
memory. In assigning a pathological value as " causes " of 
insanity to the various morbid products found after death, 
we must consider well whether they may not be the results 
of the excessive action which has gone on in the head. The 
various effusions, extravasations, and layers of exudation 
found among the cerebral membranes may be given as in- 
stances, with other appearances hereafter to be mentioned. 
Important questions may hinge upon our interpretation of 
these, as, for example, the duration of mental disease, esti- 
mated by post-mortem examination, — a point not unfre- 
quently raised in the Court of Probate. 

We may conclude that the ordinary forms of insanity, 
such as we term mania, monomania, or melancholia, are 
rarely caused by morbid growths within the head, or by 
acute inflammation of the brain or membranes; that where 
they are thus produced, there is usually a strong predisposi- 
tion depending on other pathological conditions coexisting 

7 



98 THE PATHOLOGY OF INSANITY. 

in the individual; and this insanity may disappear for a time 
and then recur, being lighted up anew by the irremovable 
cause. We may learn from this what a functional disturb- 
ance insanity is, even when springing from an organized 
cause, and how strong the tendency of the individual life 
of the brain-cells is towards recovery, so long as it is not 
seriously interfered with by conflicting morbid conditions. 
In spite of the ancient theories of insanity being caused by 
black bile, I believe the liver has little to do with the 

16. Insanity 1 i • i t • n • it 

with disease pathological condition ot a patient who has recently 
become insane. In the general disorder of the sys- 
tem existing at such a time, the liver may participate, but it 
is not the cause of all the mischief, as so many, especially the 
friends, try to establish. The liver is the best abused organ 
of the body ; whatever be the matter, nine people out of ten 
ascribe the blame to the liver, and cannot be convinced of 
the contrary. Little is to be teamed from post-mortem ap- 
pearances ; there is nothing more than may be observed in 
the livers of those dying of ordinary diseases in a general 
hospital. Congestion, a softened and friable state, enlarge- 
ment rather than shrinking, are what we chiefly see. 

In the post-mortem theatre the hearts of insane patients 
it ver J frequently present morbid appearances, but we 
with disease are not to connect these with the outbreak of the in- 
sanity. Their nature indicates that they are the 
result of the long-continued, violent, and the irregular action 
of the organ during many years. That which we shall most 
commonly find in chronic cases is that the right side is very 
much thinner than usual, and probably dilated, and that the 
left ventricle is thickened. In quite recent cases the whole 
may be healthy, or possibly there is a softened, friable, greasy 
condition without loss of substance. The valves are not dis- 
eased more frequently than usual, but the right auriculo- 
ventricular opening is often very large. Dr. Sutherland 
states, in his Croonian Lectures, that of forty-two patients 



THE PATHOLOGY OF INSANITY. 99 

examined at St. Luke's Hospital in the years 1853-56, the 
heart was healthy in eight cases only. 

There is little to be said concerning the kidneys. In the 
pathology of commencing insanity they play a very 
unimportant part, and even after death they are not with disease 
often found diseased. Acute renal disease with 
albuminuria and dropsy is decidedly rare amongst the insane. 

Dj-spepsia and functional derangement of the stomach are 
common, but are not to be looked upon as primary 19 Insanity 
disorders, but rather as caused bv the disturbance of wit ^ dise a se 

7 J of stomach 

the nervous system. Vomiting is not common even andboweis. 
amongst patients who refuse their food from alleged dislike 
and want of appetite, and the whole of the phenomena of 
dyspepsia are to be studied most carefully from an objective 
point of view. We are not to be too much influenced by the 
patient's own subjective sensations : numberless are the delu- 
sions connected with the stomach and intestines. 

Similarly functional derangement of the bowels and the 
uterine organs may exist without actual disease. Obstinate 
constipation is a common symptom also to be referred to the 
nervous condition, and varying with it. Much has been 
made of an occasional displacement of the large intestine 
met with after death. The transverse colon descends and 
lies across the hypogastric region or in the pelvis. I think 
it possible that violent struggling and straining, especially 
under mechanical restraint, have something to do with this. 
We find tumors of the womb or ovaries, and are able to con- 
nect these with the insanity, and even with the delusions. 
I have already spoken of insanity in connection with the 
sexual organs, and have nothing further to add here. 

I have left till last the question of the connection of 
insanity and tuberculosis, because authors differ on 

20. Insnnitv 

this. In the "Journal of Mental Science," April, withtuber- 
18G3, Dr. Ciouston has described a variety as phthis- 
ical insanity, characterized, as he says, by suspicion, irrita- 



100 THE PATHOLOGY OF INSANITY. 

bility, unsociableness, disinclination to exert the mind and 
body, and the absence of any acute symptoms. These cases 
of pure monomania of suspicion terminate, almost all, accord- 
ing to Dr. Clouston, in tuberculosis. But not only does Dr. 
Clouston describe this special form of phthisical insanity ; 
he asserts, in addition, that tubercle is found in the bodies 
of those dying insane much more frequently than in the 
sane ; that in the former it is to be found in 60 per cent., in 
the latter in about 25 per cent. We must recollect, how- 
ever, that Dr. Clouston's statistics are based mainly on the 
records of the Royal Edinburgh Asylum, though he casually 
mentions the asylums of Prague, Vienna, and the Salpetriere. 
When, however, we turn to the carefully recorded post-mor- 
tem examinations of Dr. Boyd, at the Somerset Asylum, we 
find that of 302 examinations conducted in the years 1862— 
67, only in 61 were tubercles found. I hold that statistics 
drawn from asylum life prove little as regards the connection 
between phthisis and insanity, unless it can be shown that 
tubercles existed previous to the admission, and coexisted 
with the commencement of the mental symptoms. The fact 
of tubercle existing in the body of a patient who has died 
after twenty years in an asylum is of little import. If it 
were possible, we ought to compare with such statistics those 
of insane patients who have never been in an asylum. From 
my own experience, I should say that there is no more tuber- 
culosis among these than amongst the non -insane world. I 
have inquired at the Hospital for Consumption whether in 
that establishment any connection between insanity and 
tuberculosis is recognized, and I am assured by the senior 
physician, who is corroborated by the gentleman who has 
been the resident officer for twenty years, that no more, but 
probably a less number of cases of insanity occur there than 
in a general hospital. An insane patient is quite an excep- 
tion in the wards of the Consumption Hospital, the only head 
symptoms being in connection with tubercular meningitis. 



THE PATHOLOGY OF INSANITY. 101 

Dr. Cotton also says that it has been stated that families in 
which consumption is prevalent exhibit a strong tendency to 
insanity, but that his own experience is quite opposed to 
such a conclusion. He goes on to remark that phthisis and 
melancholia are seldom seen together ; that consumptive 
patients are, as a rule, cheerful and hopeful ; that in the 
very many absolutely hopeless cases of consumption he has 
seen, he has never suspected a tendency to suicide. Now, 
we see phthisis and insanity combined in asylums, but I am 
disposed to believe that there is no necessary connection 
between them, no connection other than may exist between 
insanity and any depressing or wasting disorder. Dr. Clous- 
ton, in his Keport of the Cumberland Asylum, 1870, says : 
" The small number of patients that have died of consump- 
tion in the asylum up to this year, and the comparatively 
small number of cases of that special form of insanity which 
I have alluded to, attest, I think, the sufficiency of our diet- 
ary, the healthy situation of the asylum, and the attention 
paid to cleanliness and ventilation in it." From this it would 
seem that Dr. Clouston himself suspects that the phthisis 
may be due to asylum influences, and not necessarily con- 
nected with the insanity. Looking at the statistics of phthis- 
ical insanity, I find that most of the cases are returned as 
mania, and that melancholia is comparatively rare. What- 
ever be the disease in the lungs, the circulation in the brain 
appears to be vigorous, as we should expect from the high 
rate of the pulse. And we know that phthisical patients, 
beyond any others, retain their mental faculties unimpaired 
to the last. 

When various pathological conditions favorable to the de- 
velopment of insanity coexist in an individual, there wants 
but some one weakening or depressing agent to bring about 
the result. And this may be effected by tuberculosis of the 
lung, or by some other disease, acute or chronic. I have 
just seen acute insanity produced or preceded in two men 



102 THE PATHOLOGY OF INSANITY. 

by disease of the bladder, in a woman by chronic vomiting. 
The pathology here is not difficult to comprehend; but we 
also read of mental disorder following the healing of erup- 
tions, ulcers, discharges, and the like. I confess that I think 
the 'post hoc and propter hoc in these cases are often con- 
founded. 

Cases are on record where an attack of insanity has passed 
21. insanity on ° upon the expulsion of a tape-worm, upon the re- 
withperipn- mov al of a piece of glass from the sole of a boy's 

eral irrita- i o j 

tion. f 00 t. or the cure of a displaced uterus. Here a cen- 

tral disturbance is caused by an irritation of a peripheral 
nerve akin to the reflex paralysis which often follows injuries 
of the periphery. Such cases warn us closely to examine into 
the condition of all patients brought under our observation, 
for by the discovery of such matters we may cure an insanity 
which otherwise might have become chronic. 

Thus have I briefly mentioned certain assemblages of path- 
ological conditions which may be found coexisting in insane 
patients, and which may warrant our calling the malady with 
which they are visited puerperal insanity, alcoholic insanity, 
and so on. I have indicated them in mere outline. At 
present we can do little more ; but as observations accumu- 
late, we shall be able to fill in this outline, and probably add 
to or subdivide these classes. That which is now so often 
called idiopathic insanity will, by the light of a clearer 
knowledge, be resolved into its true pathological colors, and 
we shall be better able to trace the connection between the 
conditions and causes of insanity and the mental manifesta- 
tions which are the symptoms of it. And here I must ad- 
vert for a moment to this classification of insanity. You will 
see that if these are varieties and divisions of insanity, they 
are not the varieties of which you have been accustomed to 
hear. I do not divide the disease into mania, melancholia, 
dementia. The latter terms express the mental symptoms ; 



TIIE PATHOLOGY OF INSANITY. 103 

the divisions I have given aim at the expression of the path- 
ological condition of the patient. But some phy- Do the mental 
sicians have thought that with certain of these J^JETX 
pathological conditions there is to be seen a pecu- the patnoiogi- 

r c cal variety ? 

liar assemblage of mental symptoms characteristic 
of that variety of insanity. Dr. Maudsley tells us that 
masturbating insanity has its proper symptoms ; Dr. Clous- 
ton thinks those of phthisical insanity are marked and pecu- 
liar, just as are those of the great majority of the cases of 
general paralysis or of climacteric insanity. These opinions 
may be quite true, but yet they explain little. The mental 
symptoms of a patient at any particular moment are the ex- 
pression of the pathological state of his brain at the time, 
and, as I have already said (p. 61), the same patient may be 
one day maniacal and the next melancholic ; or of two women 
insane after confinement, one may be melancholic, the other 
maniacal. But every person differs in mind from all others, 
though to some extent he resembles them, and he differs 
according to the physical organization of his system, his 
nervous, visceral, and muscular development. He may vary 
also at different times, vary in strength and endurance, in 
nervous as in muscular power, according as he is in or out 
of health. If we could find a dozen men exactly alike, the 
same cause of insanity would produce the same mental phe- 
nomena by producing the same pathological state of brain ; 
but as men and women vary indefinitely, it appears to me a 
mere accident if the same cause produces the same symp- 
toms. Masturbating insanity, as described by Dr. Maudsley, 
comes on in young men of about the age of twenty ; there- 
fore in their disorder they closely resemble one another. 
Climacteric insanity comes on in those who are beginning to 
decline in years and strength ; hence the symptoms are alike, 
and are chiefly those of melancholia. But if we look at the 
enormous number of cases of melancholia which occur in 
patients not in their climacteric, and if we find symptoms 



104 THE PATHOLOGY OF INSANITY. 

similar to those of phthisical insanity, or masturbating in- 
sanity, in patients who are not phthisical and who do not 
masturbate, it is obvious that a like pathological condition 
has arisen, though from some other cause or assemblage of 
causes, just as we have the same symptoms arising from 
idiopathic or traumatic tetanus and from strychnia poison. 
I believe that mental symptoms are most valuable indica- 
tions, and are not to be neglected ; that melancholia or 
mania implies a state of the nervous centres which must be 
taken into account in our prognosis and treatment ; but that 
this insane state may be brought about in the individual by 
many different pathological causes. We find every exalted 
delusion, such as is noticed among paralytics, in those who 
are not paralytic, and in paralytics we may see the deepest 
melancholia. We are told that when puerperal insanity 
commences in the first fortnight after confinement, it shows 
itself in puerperal mania ; when later, in melancholia. Here 
the difference must be due to the different state of health of 
the patient at the two dates, not to anything special in the 
exciting cause of the disease. 

If, after due consideration of the causes and symptoms of 

insanity, coupled with an accurate estimate of the health 

and strength of the patient at the time of the outbreak, we 

ask ourselves the question, what is the pathology 

What is, then, «,.-,. V n l • l • 

the pathology of this disordered state of brain and mind mani- 
mty? festation, what can we answer? A weakly person 
may drift into a depressed condition, which we call melan- 
cholia, remain in it for months or years, and then gradually 
recover ; a young and vigorous subject may be almost sud- 
denly attacked by acute delirium, pass a week or longer in 
a state of raving mania wholly without sleep, then sleep, 
and recover perfectly in a month. Another experiences a 
shock or fright, falls into a condition of blank demented 
idiocy, and yet recovers. Another gradually becomes altered 
and eccentric, conceives some odd delusions and fancies, and 



THE PATHOLOGY OF INSANITY. 105 

remains so for the rest of his days. All these are insane, 
but how different is their insanity, and how different their 
bodily appearance, development, age, and strength ! Can we 
suppose that the condition of them all is the same, or nearly 
the same ? 

I am inclined to say that in all these cases the brain is 
insufficiently fed; that the supply from which it is to derive 
its power of working is in defect ; but this deficiency may, 
I think, depend upon various conditions. There may be an 
absolute defect of blood, an anaemia, or a blood too poor for 
its purpose, or poisoned by deleterious ingredients. The 
defect may be from too much blood, causing by its pressure 
a congestion or stasis, and arresting in this way the supply 
which should be conveyed to every cell. And the increased 
arterial circulation, ending in obstruction and stasis, may be 
due to diminished arterial tension, depending on disturbances 
of the vaso-motor system, arising in ways of which we can 
take no cognizance. We know that in almost all acute in- 
sanity sleep is absent, or at any rate greatly diminished; and 
we know that when such a medicine as hydrate of chloral 
produces sleep, it increases the arterial tension, for this is 
shown by the sphygmographic trace. 

If arterial tension were to be so increased as to arrest the 
flow of blood, delirium or convulsions might occur, and it is 
supposed that this actually happens in epilepsy. We have 
seen how close is the connection between epilepsy and in- 
sanity, and how the one may take the place of the other. 
Chorea, too, has been thought to be due to embolic closure 
of the arteries, and there is much in common between chorea 
and insanity. 

In short, from whichever side we look at the disease, 
whether we look at the sthenic or the asthenic forms, or con- 
sider it in the young or the old, in those previously well or 
in the victims of other diseases, there seems in all some reason 
for thinking either that the nutrition and metamorphosis of 



106 THE PATHOLOGY OF INSANITY. 

the brain are in parts impeded or rendered irregular, or that 
of the whole disordered or obstructed. Such disorder may 
be overcome quickly, and things may return at once to their 
normal state, or there may be absolute defect, and only 
by months of feeding and care will the anaemia be overcome, 
and the brain be again nourished and restored to its former 
level. The traces which we find of hyperemia of the brain 
may indicate that there has been excessive arterial action, 
and the fierce excitement, the hilarity, the flushed face and 
quickened pulse, may all point to the same fact ; but this 
hyperemia, no less than an opposite state of anaemia, may 
denote a want of healthy conversion, a want of the normal 
renewal of the wasting nerve-element. As fever in an old 
demented patient will sometimes bring back, while it lasts, 
mental vigor and clear intelligence, the pulse being quickened 
and the blood-flow increased, so will it in a healthy subject 
cause delirium by the obstruction caused by the abnormal 
rush of blood in the cerebral vessels. 



LECTURE V. 

Morbid Appearances — In Acute Insanity — Meninges — Brain — Vessels 
— In Chronic Insanity — Yessels — Brain — Nerve Cells and Tubes — 
Connective Tissue Growths — The Insane Ear — Classification — Vari- 
ous Systems — Points to be observed. 

Vague and uncertain as are our speculations upon the 
pathological conditions of insanity, they receive little if any 
help from the changes noticeable after death in the brains of 
the insane. That which I have to say, concerning the post- 
mortem appearances and the morbid products observed in such 
patients, is said with the utmost diffidence, because it amounts 
in truth to very little, and rests on the researches and labors 
of others, not on my own. I claim no credit for the discovery 
of the various lesions described. Concerning these phenomena 
observers differ, and differ widely ; in fact, the method of ob- 
servation of each one differs from that of others, and according 
to the method so is the result observed. Yet we may be well 
assured that a time will come, probably not long hence, when 
much more will be laid down as clearly ascertained fact than 
has been known hitherto. We wade through wearisome 
pages of examinations, conducted in the rough-and-ready 
method of bygone days, when nothing beyond a scalpel was 
called in to assist in the process — when brains were weighed 
with pound weights, sliced up, and flung away — when gray 
matter and white were the two divisions of which, and of 
which alone, notice was taken — when the coverings rather 
than the brain itself attracted attention. Before pathology 
could note morbid changes, it was necessary that minute 
anatomy should further advance. Now we are in a position 



108 MORBID APPEARANCES. 

to speak of changed tissues, knowing in a much higher de- 
gree the normal condition of those we examine. 

But even now, after so much has been done, we are but 
at the threshold of this great field of research. I believe 
that any one who patiently and skilfully examines the brain 
of the insane, not of ten or twenty, but of many hundreds, 
will throw an entirely new light upon mind pathology and 
brain pathology. No brain has been satisfactorily examined 
that has only been looked at with the naked eye, and all 
the records of former autopsies made in this fashion are as 
so much waste paper. Morbid phenomena studied by the 
aid of the microscope reveal themselves as definite changes 
and lesions, instead of indefinite "softening," "hardening," 
"thickening," "discoloration," such as are enumerated by 
naked-eye observers. And no brain can be said to be prop- 
erly examined that has not been examined throughout. Not 
every cell and nerve-tube need pass over the field of the 
microscope; but parts of every region and district are to be 
submitted to scrutiny — not only those obviously changed, but 
others also at a distance. 

If we consult the records of the deaths of the insane, it will 
at once be seen that the proportion of those who die of re- 
cent and acute insanity is very small. The majority will be 
patients who have been insane for some years, fewer will be 
the cases for some months, and only here and there shall we 
discover one whose malady has lasted but a few weeks or 
days. In some the insanity may be said to be the cause of 
death, but many chronic patients die of other diseases : — of 
bronchitis, phthisis, and so on. From what we find after 
death, we have to infer the morbid process which has gone 
on in life. The appearances found in the chronic insane are 
not those met with in recent and acute insanity. The for- 
mer are the result of a disease which has slowly dragged 
itself along for years, the latter indicate the beginning of 



MORBID APPEARANCES. 109 

the disease ; and from a comparison the one with the other, 
we are left to infer the nature thereof. 

Now, scanty and imperfect as are the observations of mor- 
bid appearances found in acute and chronic cases Appearances 
of insanity, the tale they tell is consecutive and f^^^ se 
certain, and is illustrated by the changes and dis- cent insanity. 
eases of other organs. I will mention first that which is 
observed, whether by the naked eye or by the aid of the 
microscope, in patients dying of acute and recent insanity, 
and then on reviewing the phenomena found in the brains 
of patients who have been insane for years, I think it will 
be found that the pathology of the one class tallies with that 
of the other. 

A man becomes maniacal ; his mania passes into violent- 
delirium, and in the delirium he dies perhaps in a week: 
it is the most rapid mode of death in a state of insanity. 
There may have been no bodily complication, no assignable 
cause ; the case may become what is called genuine " idio- 
pathic" mania. We open the head, and expect to find suffi- 
cient to account for death. All the organs of the body be 
quite healthy, and yet that which is seen in the brain does 
not seem enough to kill a strong man so speedily. But in 
truth the appearances point to the great storm that has raged 
there during the last week or fortnight of life — a storm that 
has brought about death by its violence, though the traces 
may by some be summed up as great vascularity or congestion 
of the brain and its membranes. 

To take the first naked-eye appearances, we find signs of 
violent disturbance manifested in the meninges, the The 
vehicles of the blood-supply of the brain itself. menin s es - 
" Sinuses and veins of pia mater full of blood — considerable 
serous effusions in subarachnoid space." This was in a fe- 
male who died of mania in fourteen days. " Pia mater much 
congested, arachnoid slightly opalescent." This also was in 
a female. Opacity of the arachnoid is common; you will 



110 MORBID APPEARANCES. 

find it often in patients not insane ; but in the cases of which 
I am speaking it denotes excessive action tending to menin- 
gitis. So violent may it have been, that not unfrequently 
we find effusions of blood from the rupture of small vessels 
between the membranes. And much serous effusion is com- 
monly found, which probably precedes death only a short 
time, and accompanies the coma in which so many of these 
patients sink. In others who have had previous attacks, or 
have been excitable, semi-insane, and constantly liable to 
disturbance of the cerebral circulation, we find great thick- 
ening and eburnation of the cranial bones, and extensive 
adhesion of the dura mater. These appearances point to a 
low inflammatory and degenerative change which has been 
going on for some time, and you will constantly see them in 
patients not insane. When we remove the pia mater, and 
this in a recent case can generally be accomplished without 
difficulty, we find the same traces of violent action. The 
brain is not uniform and healthy in tint. In places it is 
discolored from pink to purple, and is often softened. Its 
structures, cells, tubes, and connecting tissue are obviously 
altered and damaged by the hyperemia which has existed. 
There has been great vascularity; on slicing it we see many 
bleeding puncta, and the vessels have manifestly been dilated. 
As might be expected, there are to be found in the brains 
of the insane extravasation of all kinds and degrees, 

The brain. # . . 

especially in those who have died after a brief period 
of violent excitement. Blood-cysts are found in the cavity 
of the arachnoid, arid stains and spots of extravasated blood 
are seen on the surface of the convolutions and in the sub- 
stance of the brain : capillary apoplexies, extravasated blood- 
corpuscles, and yellowish or reddened brain matter, are ap- 
pearances well known to those who have examined such 
patients after death. 

In the membranes we rarely find marks of active inflam- 
mation, but there may be great adhesion of the dura mater 



MORBID APPEARANCES. Ill 

to the bone, and adhesion of the pia mater to the convolu- 
tions, so that in removing it we tear away the brain substance. 
And the arachnoid will often be milky and thickened, or 
atrophied and perforated. 

The bone is often enormously thickened, the diploe being 
absorbed, the whole having undergone a retrograde meta- 
morphosis. 

In a thesis read before the University of Oxford in 1867, 
I propounded the theory that the cause of delirium Blocking of 
and death in acute and rapid cases of insanity, deli- the vessels - 
rium tremens, and the like, is stasis of the capillary circula- 
tion, the result of pressure or inflammatory changes in the 
blood. In a paper already referred to (page 52), published 
in the " British Medical Journal" of January 23, 1869, Dr. 
Charlton Bastian narrates certain post-mortem appearances 
found by him in the brain of an intemperate man, who died 
of erysipelas of the scalp, following a fall on the head, with 
violent delirium. These, I think, strongly confirm the con- 
jectures I put forth in 1S67 — conjectures based chiefly on 
Mr. Lister's Experiments and Observations on Inflammation, 
published in the Philosophical Transactions, 1859. To the 
naked eye all parts of the brain showed a decidedly abnormal 
amount of vascularity, and this was particularly evident on 
the venous side of the circulation. The veins of the surface 
of the lateral ventricles, and those of the choroid plexuses, 
were all notably distended with dark blood, though there 
was no obstruction in the venae magna? Galeni or in the 
straight sinus. The lateral ventricles, however, contained 
only a small quantity of pale serum. The " red points" were 
very abundant wherever sections were made through the 
white substance of the hemispheres. On microscopical ex- 
amination of some minute vessels and capillaries taken from 
the gray matter of the convolutions, every specimen looked 
at showed minute embolic masses in various parts of the 
course of the small arteries and capillaries, of a most unmis- 



112 MORBID APPEARANCES. 

takable nature, though apparently of recent origin. Distinct 
masses, of irregular shape and size, could be seen, made up 
of an agglomeration of white blood-corpuscles. In some 
cases the masses were small, and formed by the union of 
three or four white corpuscles only ; whilst in others large 
irregularly-shaped aggregations could be seen within some of 
the bigger vessels, which may have been made up by the 
mutual adhesion of two or three hundred of such corpuscles. 
The largest mass actually measured was T J^ in. long by s JjJ 
in. broad. In other parts large rounded bodies were seen, 
whose nature was not at firSt sight so obvious, though after 
a little careful examination I became convinced that these 
had, in all probability, been formed by the complete fusion 
of corpuscles into a single mass, which had afterwards under- 
gone more or less of a granular degeneration." 

In commenting on this case, Dr. Bastian mentions others; 
one, a case of rheumatic fever, with delirium ; another, of 
double pneumonia, progressing favorably, when maniacal 
delirium set in, lasted about thirty-six hours, and then gradu- 
ally subsided. The latter was, in fact, an instance of mania 
arising in the course of an acute disease, akin to that already 
mentioned, which Dr. Weber has termed the " delirium of 
collapse." Dr. Bastian was strongly impressed at the time 
with the probability that the delirium, in the latter case at 
least, was due to some accidental plugging of minute vessels 
of the brain by means of aggregated white blood-corpuscles, 
and to the consequent total disturbance in the incidence of 
blood-pressure, and in the conditions of nutritive supply in 
the convolutional gray matter of the brain. "It was there- 
fore with a feeling of considerable interest that I proceeded 
to examine the brain in this case of erysipelas of the scalp, 
which had been associated during life with delirium and 
stupor." 

From the actual appearances described by Dr. Bastian, and 
from the similarity of the symptoms in acute insanity, we 



MORBID APPEARANCES. 113 

may infer that the violent delirium which so often exists 
may arise from some such blocking of the vessels ; and if 
death occurs, it may be the result either of this obstruction 
increasing till it causes coma or convulsions, or of exhaustion 
supervening upon the delirium. It is to be remembered that 
delirium occurring in the course of fevers, pneumonia, and like 
disorders, almost always passes off, and recovery takes place. 
Many transitory attacks are likewise seen in what is called 
hysterical or transitory mania. Whether the disorder in the 
brain circulation depends on some disturbance arising out of 
the vaso-motor system, such as Spasm of the arteries, or on 
other causes producing temporary arrest of the blood-flow, it 
is clear that the evil soon passes away, and it is not likely, 
even if the patient were to die soon after, that we should 
discover post-mortem appearances sufficient to account for the 
mental symptoms. Where, however, delirium runs on to 
death after a week or upwards, such a condition as that de- 
scribed by Dr. Bastian may be found, and should certainly 
be looked for. 

So far as I gather from published reports, the cervical 
ganglia of the sympathetic, which are closely connected with 
the brain circulation, have been examined but seldom in pa- 
tients dying insane. I cannot tell you, therefore, whether 
morbid appearances are to be found there. It is possible that 
by disturbance carried thither from distant parts considerable 
effects might be produced without much trace being left, but 
at any rate I wish that they could be examined by some of 
our leading microscopists. 

There seems to be a prevailing opinion abroad amongst 
pathologists that acute mental symptoms, especially delirium, 
are brought about by obstruction of the cerebral blood-flow ; 
and even the chorea often noticed in connection with rheu- 
matism has been thought to be caused by emboli carried to 
the nerve-centres from the heart. Obstruction of the circu- 
lation is probably the condition, and the greater the obstruc- 



114 MORBID APPEARANCES. 

tion the more acute will be the delirium. But I think it will 
be found that this obstruction may arise from a number of 
various causes. It is clear that it is often temporary, and 
must depend on something easily and quickly removed. It 
may be caused by some spasm of arteries, and may depend 
on the vaso-motor system. It may arise from some inflam- 
mation of the part, or of adjoining parts, as in Dr. Bastian's 
case. It may depend on such a poison as that of gout or 
rheumatism, or it may be not an obstruction, but an anaemia 
produced by a failure of the heart's action, or a poverty of 
oxygen-carrying red corpuscles. By due examination and 
weighing of such matters, we may connect the causes of in- 
sanity with the actual pathological changes, and establish a 
much closer connection between them than has hitherto ex- 
isted. Above all, there is needed an accurate observation of 
the brain of those dying of acute insanity. I have quoted 
Dr. Bastian's remarks, as worthy of the greatest attention; 
but it is to be remembered that the case he examined was 
not one of ordinary insanity. Moreover, we want the ex- 
amination, not of two or three, but of many patients, and 
more must be determined as to what are normal, and what 
abnormal phenomena, amongst those revealed by the micro- 
scope. We know little as yet concerning the changes which 
occur in the blood and tissues at the time of death, or imme- 
diately after. 

When we examine the brains of patients who have died 
. A . after a Ions: period of insanity, and seek for traces 

Examination o i •/ i 

of the chronic f their malady, our labors are better rewarded. 
We find degeneration of all the structures which 
join in the working of the brain, and an increase of the 
lowest tissues, together with a growth of adventitious and 
abnormal products, which supplant the healthy structure, 
and subvert its function. We find, in fact, the same evi- 
dences which testify to degeneration and decay of the other 
organs of the body; and, so far as we can observe, these 



MORBID APPEARANCES. 115 

changes appear to be the ultimate end and result of the 
acute disease which was first manifested in symptoms which 
exist in the early stages of almost every variety of insanity. 

I have said that the appearances found in those who die 
of acute insanity point to a violent disturbance of the cere- 
bral circulation. The changes we meet with in the chronic 
insane point to the results of this disturbance, to damage of 
the vessels, to extravasation of their contents, to a consequent 
interference with their life and function, and nutrition of the 
tissues they supply. Degeneration and atrophy have wasted 
the cells and tubes, while more lowly organized structures — 
bone, connective tissue, fatty and amyloid corpuscles — flour- 
ish and abound, as they ever do where the normal tissues 
and the normal nutrition are at fault. 

What, then, are the changes observed in the bloodvessels? 
Various pathologists have directed their attention to these, 
and have recorded not a few deviations from the healthy 
state. 

One which Dr. Sankey has described in the "Journal of 
Mental Science," 1 is an hypertrophied condition 
of the walls of the small arteries and capillaries. () / ,H 
Struck by Dr. George Johnson's discovery of hyper- 
trophy of the small renal arteries, Dr. Sankey ex- 
amined those of twenty -five insane patients. Of eight cases 
of general paralysis, he found the hypertrophy in one only. 
Of seven cases of chronic dementia, all save one presented 
some amount; the one exception was the youngest patient, 
thirty-five years of age. Two cases of epilepsy, and one of 
acute mania, apparently presented no deviation from the 
normal condition. Of seven cases of chronic insanity, hyper- 
trophy existed in four. Dr. Sankey is of opinion that this 
alteration indicates that the muscular coat of the arteries 
has had at one period an excessive amount of work to do. 

1 January, 1869. 



the walls of 
the small 
arteries. 



116 MORBID APPEARANCES. 

The cause of the excess of work may, of course, vary in- 
definitely. Dr. Sankey thinks that an impure state of the 
blood may frequently be at the bottom of it. However this 
may be, we know that violent cerebral excitement and action 
accompany the acute stage of insanity, and that hypertrophy 
may be the result; and, moreover, that in this way there 
may be great disturbance of the circulation and nutrition of 
the brain. 

There is also another condition of the small arteries and 
Twisting of capillaries not coexistent with hypertrophy, but on 
the arteries, ^e contrary, found where the latter is not, yet 
apparently brought about by the same cause, — the violent 
action which leaves so many traces behind. An extreme 
varicosity of the capillaries is to be seen, a kinking or twist- 
ing together with dilatation, as if at some period so great a 
rush of blood had taken place that the vessel could not carry 
it on, but had become distorted, strained, and twisted in the 
attempt. This appearance Dr. Sankey has found in the sub- 
jects of general paralysis in which hypertrophy seldom exists, 
and he thinks that the vessel not interposing to check the 
blood-flow, owing possibly to deficient nervous power, does 
not become hypertrophied, but undergoes the other change 
which he has described. 

Nor are these the only changes which the bloodvessels 
undergo. Attention has been directed lately to their sheaths, 
to the canals in which they run — the perivascular canals, as 
they are called — and also to certain holes existing in the 
brain tissue, which seem to have their origin in the vessels. 

Upon the vessels a deposit of hyaline connective tissue has 
sheaths of been seen, studded with nuclei and proliferated neu- 
vesseis. rogliar cells, taking its origin either from the nuclei 
of the walls, or from the neuroglia beyond them. Dr. Lock- 
hart Clarke points out that in healthy brains the capillaries 
and small arteries are surrounded by secondary sheaths, but 
the morbid sheaths are thicker, darker, and studded with 



MORBID APPEARANCES. 117 

hsematoidin, or other deposits. It is common also to find 
the vessels in a state of fatty degeneration. 

The perivascular canals in which the vessels run have 
been found in a very dilated condition in the insane, espe- 
cially in those dying of general paralysis, the vessel lying as 
if adherent to one side. This perivascular covering is some- 
times transparent, sometimes opaque, and presents variations 
and changes manifestly morbid. 

Somewhat akin possibly to this dilatation of the peri- 
vascular canals, or a further stage of the process, are Ho iesinthe 
certain holes described by Dr. Lockhart Clarke, and brain - 
found by him in the white substance of the convolutions and 
optic thalamus of a patient who died of general paralysis. 
"On making slices with a very sharp instrument through 
the convolutions, their central white substance presented 
numerous cavities, of a round, oval, fusiform, crescentic, or 
somewhat cylindrical shape, and varying from the size of a 
small pea or a barleycorn to that of a grain of sand, so that 
the surfaces in some sections strikingly resembled the cut 
surface of Gruyere cheese, while those of others had more 
resemblance to a slice of the crumb of bread. For the most 
part they were empty, had perfectly smooth walls, without 
any lining membrane, and seemed as if they had been 
sharply cut out of the tissue. A few, however, were found 
to contain what appeared to be the remains or debris of 
bloodvessels, mixed with a few granules of hsematoidin. One 
or two were found to communicate with the surface of the 
convolutions through the natural fissures between them, and 
to contain a perfect bloodvessel, with its branches. On re- 
moving the bloodvessel, the walls of the broad but shallow 
cavity was seen to be perforated by a multitude of minute 
orifices, through which the finer branches of the vessel had 
passed. These latter circumstances, together with a com- 
parison of the shape and course of some of the natural fis- 
sures transmitting bloodvessels from the surface, render it 



118 MORBID APPEARANCES. 

almost certain that at least the greater number of these 
cavities were perivascular spaces or canals, which originally 
contained bloodvessels, surrounded by their peculiar sheaths, 
and which subsequently became empty by the destruction 
and absorption of those vessels." 1 

Doubtless you are aware that Dr. Dickinson has discovered 
similar holes in the brain and spinal cord of diabetic patients. 
The preparations in his possession appear to throw great 
light on the mode in which these holes are produced, and 
illustrate not a little the pathology of insanity. 

In more than one a bloodvessel is seen in a state of great 
congestion, so great that the blood-corpuscles have apparently 
transuded through the walls of the vessel, and invaded the 
tissue in which it is imbedded. If the patient does not die in 
this stage, the acute congestive stage of insanity, we may sup- 
pose that the exuded blood becomes absorbed, and then a hole, 
possibly with ragged edge, is left behind. This is the view 
Dr. Dickinson takes of the origin of these holes, and it seems 
very probable. Drs. Tuke and Rutherford 2 say that they 
observed holes in the white matter of the brain — holes differ- 
ing, however, from those described bv Dr. Lockhart Clarke, 
" inasmuch as they have no apparent connection with blood- 
vessels, and are manifestly due to a solution of the continuity 
of nerve-elements, as is evident from the ragged character of 
the walls." It is, however, possible, I think, that the latter 
appearance may be due to invasion and subsequent absorp- 
tion of extravasated blood, and to absorption of the remains 
of the vessel itself. 

The whole points to violent action producing hypertrophy 
of the walls, variocosity, congestion, extravasation, absorp- 
tion, and destruction of nerve-tissue. 

Another result is an interference with the nutrition of all 
parts. The vessels themselves are strained and twisted, and 

1 Journal of Mental Science, Jan., 1870. 

2 Edinburgh Medical Journal, Oct., 1869. 



MORBID APPEARANCES. 119 

become fatty, or disappear by absorption, and degeneration 
of various kinds attacks the gray and white matter, the 
nerve-cells, and nerve-fibres. 

The cells of the convolutions, and also of the corpora 
striata, and other nerve-centres of the mesocephalon, ^ T 

L ' .Nerve-cells. 

are often found in a state of pigmentary degeneration. 
The cell may contain a few pigment granules, or may be full 
of them, retaining its cell outline, or it may be completely 
broken up, the pigment granules remaining in heaps to mark 
the place of the original cells. And instead of the pigmentary 
there may be a fatty degeneration, the cells being filled with 
fat granules. There may be merely an aggregate of fat 
globules, with the outline and nucleus of nerve-cells, or half 
of the outline of the cell may be preserved, the other being 
replaced by a margin of fat globules. Nay, calcification of 
the cells has also been discovered, phosphate of lime occupy- 
ing and rendering them opaque. And, in addition to these 
degenerative metamorphoses, we find the cells atrophied. 
Atrophy occurs from a variety of causes, from pressure of 
other growths, cysts, or extravasations. It arises from ar- 
rested nutrition, or from the decay of old age. Atrophy of 
the cells of the cortical substance is often met with in the 
chronic insane, as it is in those who have died from the more 
rapid ravages of general paralysis. 

Atrophy may also be observed attacking the nerve-tubes; 
and Drs. Tuke and Rutherford tell us that in a case 
of chronic dementia, complicated with chorea, the 
nerve-tubes of the anterior and posterior roots of the spinal 
nerves were found to have undergone a pigmentary degenera- 
tion similar to that noticed in the nerve-cells. 

More attention has, perhaps, been paid to the changes in 
the connective tissue than to those of any other part connective 
of the brain. A morbid increase has been described tissue - 
by several writers — Rokitansky, Rindfleisch, and others — 
and the gray degeneration or sclerosis of many authors ap- 



120 MORBID APPEARANCES. 

pears to be due to a modification of this connective tissue. 
Referring to the valuable paper of Drs. Tuke and Rutherford, 
from which I have already quoted, I find the following de- 
scription : " We have observed this lesion only in the white 
matter of the brains examined by us. As to the nature of 
the morbid change, our observations lead us to agree with 
Rokitansky in regarding it as primarily a modification of the 
connective tissue. In the spinal cord, medulla oblongata, 
and pons, it appears to us that the connective tissue or neu- 
roglia is a nucleated, transparent, homogeneous, non-fibrillated 
matrix, representing the fibrillated connective tissue of the 
spinal cord. Owing to the extreme fineness of the nerve- 
tubes of the white matter of the brain, as compared with 
those of the spinal cord, an inquiry into the diseased condi- 
tions of the white matter of the former is much more difficult 
than in the case of the latter ; but a careful inspection of 
numerous finely-prepared sections, by means of a magnifying 
power of 800 diameters linear (Hartnack's immersion lens 
No. 10, eye-piece No. 3), has resulted in the demonstration 
that fibrillation and increase of the neurogliar matrix, to- 
gether with proliferation of its nuclei, are the essential 
changes in gray degeneration, as Rokitansky has already 
pointed out. Sometimes proliferation of the nuclei precedes 
fibrillation of the matrix, at other times the converse holds 
good. Sometimes there is a marked proliferation in the 
nuclei of the capillary walls in the diseased tracts, but we 
have not been able to confirm Rindtleisch's observation that 
the diseased process invariably starts from these. Indeed, 
our specimens show that the morbid change just as often be- 
gins at a distance from, as in the immediate neighborhood of, 
the vessels. Regarding the fate of the nerve-tubes in the 
diseased tracts in the white matter of the brain, our observa- 
tions, owing to the fineness of these elements, scarcely enable 
us to speak with confidence. They appear, however, to 
undergo atrophy, and this need scarcely be doubted, seeing 



MORBID APPEARANCES. 121 

that they certainly do so under similar conditions in the 
spinal cord." Dr. Rutherford also describes a lesion consist- 
ing of a patch where the nuclei of the neuroglia are prolifer- 
ated and surrounded not with fibres, as in the gray degenera- 
tion or sclerosis, but with semi-transparent, finely granular 
material. He also describes another lesion, termed by him 
miliary sclerosis, which consists of semi-opaque whitish spots, 
resembling very small millet-seeds, and is almost confined to 
white nerve-matter. When far advanced, the spots are dis- 
cernible with the naked eye, and consist of semi-opaque 
molecular material, lying amid a few exceedingly delicate 
colorless fibres. The cell-like masses probably originate in 
the nuclei of the neuroglia, not in the nuclei of the vascular 
walls. There is no increase of the connective tissue or neu- 
roglia, which at once distinguishes it from the gray degen- 
eration of Rokitansky or Rindfleisch. 

Granulations of the lining membrane of the ventricles 
have been thought by M. Joire to be peculiar to general 
paralysis, which they are not. They have been observed in 
old-standing cases of mania and dementia, together with 
similar granulations of the pi a mater of the parietal and 
occipital lobes and medulla oblongata. They are no doubt 
an aggregated and abnormal condition of the epithelial cells, 
and seem to contain a homogeneous substance, probably 
exuded lymph. 1 Amyloid and colloid corpuscles are to be 
found in almost all old cases of insanity. Controversy exists 
regarding their nature, but the majority consider them to be 
pathological products. These are of two sizes, the larger 
being found in both the gray and white matter of the brain; 
the smaller chiefly on the surface of the convolutions, me- 
dulla oblongata, and- spinal cord. 

There are to be seen occasionally in the brains of the 
insane, appearances denoting that there has been at 

i . n Tumors, &c. 

some time or other an injury of the head, m the 

1 Tuke and Rutherford, loc. cit. 



122 MORBID APPEARANCES. 

shape of old extravasations, remains of blood-cysts, and the 
like, which point to events which may have been the cause 
of the insanity years before. And it is to be noted that such 
patients may not have been always insane since the date of 
the injury. They may have recovered, and again become 
insane, again to recover. So great is the tendency to re- 
covery on the part of nature, and so great the tendency to 
recurrence on that of the disease, that alternations may take 
place even when actual changes are to be found in the brain. 
And the same remark applies to tumors and other growths 
of similar nature. As some people live without symptoms 
up to the day when they die of these, so others become 
insane, and yet again recover, even when the tumor is still 
present and growing. I need say little about such maladies 
as abscess, tumor, or cysticercus, because, although they are 
found in the insane, they are met with still more frequently 
in those who die in the wards of general hospitals, display- 
ing mental symptoms of every kind — delirium, imbecility, 
coma, and paralysis — without insanity in the ordinary ac- 
ceptation of the word. 

There is one morbid appearance peculiar, I believe, to the 
The insane insane, which may be mentioned here. It is called 
ear. ^ ie "i nsane ear," or hcematoma auris, and is an 

effusion of blood under the perichondrium, between it and 
the cartilage, or, according to others, within the cartilage. 
It may come on gradually, or even quite suddenly, in a night, 
may attain a large size, and appear at the point of burst- 
ing. I have known a slight oozing, but it seldom bursts. 
Slowly and gradually it shrinks, and becomes absorbed, 
leaving the ear withered and shrivelled. Of a man with 
such a shrivelled ear, it may be safely predicated that at 
some time he has had an attack of insanity. When it ap- 
pears, the prognosis is said to be unfavorable, and it certainly 
occurs most frequently in paralytic and chronic insanity. 
Some have asserted that it is always the result of violence. 



CLASSIFICATION. 123 

I cannot say if this be so, but in two cases it was certainly 
due to it. In one, the patient fell out of bed, striking the 
ear. In the other, it followed the holding of the head, ne- 
cessitated by refusal of food and medicine, and consequent 
forcible feeding. It has been supposed that it arises in many 
instances from the mere weight of the head as it rests on the 
pillow. 

CLASSIFICATIONS OF INSANITY. 

Great differences of opinion have existed for many years 
as to the classification of insanity and insane patients, and 
various systems and principles have been laid down. The 
old writers divided the disorder into Mania and Melancholia: 
Arnold (1782) into Ideal and Notional insanity; Pinel makes 
four divisions, Mania, Melancholia, Dementia, and Idiocy; 
Esquirol adds another, Monomania. Guislain's classification 
runs thus: 1. Phrenalgia, or Melancholy; 2. Phrenoplexia, 
or Ecstasy; 3. Hyperphrenia, or Mania; 4. Paraphrenia, or 
Folly; 5. ltIeophre?iia, or Delirium; 6. Aphrenia, or Demen- 
tia, Dr. Conolly speaks of Mania, Melancholia, and De- 
mentia; Dr. Prichard of Moral and Intellectual Insanity; 
Dr. Bucknill says that insanity may be Intellectual, Emo- 
tional, or Volitional; Dr. Noble's division gives Emotional, 
Notional, and Intelligential disorder. Dr. Daniel Tuke di- 
vides it according to the disturbance of — 1. The Intellect; 
2. The Moral Sentiments ; 3. The Propensities ; and his 
division is as follows: Idiocy, Dementia, Delusional Insanity, 
Emotional Insanity, Mania. Then, again, M. Morel 

. Morel. 

rejects all these divisions as artificial, and based 
merely upon the symptoms of the disease, or on supposed 
divisions of the human mind, and he proposes to divide it 
strictly according to its etiology into six groups: 1. Cases of 
Hereditary Transmission ; 2. Toxic Insanity ; 3. Those re- 
sulting from the transformation of other Neuroses ; 4. Idio- 
pathic Insanity; 5. Sympathetic Insanity; 6. Dementia. I 
will not stop to comment on the imperfections of this classi- 



124 CLASSIFICATION. 

fication ; suffice it to say, that it is not even what it professes 
to be, serological. 

The latest writer, so far as I am aware, who divides insanity 
Maudsiey. according to the mental symptoms, is Dr. Maudsley, 
whose classification is as follows : 

I. Affective or Pathetic Insanity. II. Ideational Insanity. 

1. Maniacal Perversion of the Affective 1. General. 

life. Mania sine delirio. a. Mania, •> Acute. 

2. Melancholic depression without delu- b. Melancholia, J Chronic. 

sion. Simple Melancholia. 2. Partial. 

3. Moral Alienation Proper. Approach- a. Monomania. 

ing this, but not reaching the degree b. Melancholia. 

of positive insanity, is the Insane f Primary. 

m , 3. Dementia, \ n 

Temperament. ' I Secondary. 

4. General Paralysis. 

5. Idiocy and Imbecility. 

At the International Congress of Alienists, held in Paris 

The inter- * n 1867, there was adopted a system of statistics pre- 

con-rTsI P are d by a committee appointed for that purpose, 

and the following classification was put forward as 

denoting the typical forms of the disease : 

I. Simple Insanity, embracing the different varieties of 
mania, melancholia, and monomania, circular insanity 
and mixed insanity, delusion of persecution, moral in- 
sanity, and the dementia following these different forms 
of insanity. 

II. Epileptic Insanity, or insanity with epilepsy, whether 
the convulsive affection has preceded the insanity, and 
has seemed to have been the cause ; or whether, on the 
contrary, it has appeared, during the course of the mental 
disease, only as a symptom or a complication. 

III. Paralytic Insanity. — The commission regards the dis- 
ease called general paralysis of the insane as a distinct 
morbid entity, and not at all as a complication, a termi- 
nation of insanity. It proposes, then, to comprehend 
under the name of paralytic insane, all the insane who 
show in any degree whatever the characteristic symp- 
toms of this disease. 



CLASSIFICATION. 125 

IV. Senile Dementia, which we would define as the slow 
and progressive enfeeblement of the intellectual and 
moral faculties, consequent upon old age. 

V. Organic Dementia, a term by which the commission 
means to designate a disease which is neither the de- 
mentia consequent upon insanity or epilepsy, nor para- 
lytic dementia, nor senile dementia, but that which is 
consequent upon organic lesion of the brain, nearly 
always local, and which presents, as an almost constant 
symptom, hemiplegic occurrences more or less pro- 
longed. 

VI. Idiocy, characterized by the absence or arrest of de- 
velopment of the intellectual and moral faculties. Im- 
becility and weakness of mind constitute, hereof, two 
degrees or varieties. 

VII. Cretinism, characterized by a lesion of the intellectual 
faculties, more or less analogous to that observed in 
idiocy, but with which is uniformly associated a char- 
acteristic vicious conformation of the body, an arrest of 
the development of the entirety of the organism. Out- 
side of these typical forms there are such as — 

1. Delirium tremens. 

2. Delirium of acute diseases : traumatic delirium. 
3/ Simple epilepsy. 

A committee of the Medico-Psychological Association, ap- 
pointed, in 1869, for the purpose of taking into con- committee 
sideration certain questions relating to the uniform of Medic °- 

A ° Psychological 

recording of cases of insanity, and the medical Association. 
treatment of insanity, recommends that cases should be 
classified according to two methods — 1. That depending on 
the bodily causes and natural history of the disease, as pro- 
posed by Dr. Skae ; 2. That proposed by the International 
Congress of Alienists, as given above. 

The following table is put forth by this committee as a 
specimen of the way in which cases may be arranged : 



126 



CLASSIFICATION. 



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CLASSIFICATION. 



127 



Class II. — Idiophrenic Insanity. 



Dr. Skae's division I have already given. A modification 
of it has been proposed by Dr. Batty Tuke, of the 
Fife Asylum. He enumerates seven classes of in- 
sanity, and twenty-nine sub-classes. 

Class I. — Insanity resulting from ar- -j 
rested or impaired development of t Idiocy, congenital and acquired, 
the brain. J 

Sthenic and Asthenic Idiopathic In- 
sanity. 
Phrenitic Insanity (Inflammatory). 
General Paresis. 
Paralysis with Insanity. 
Traumatic Insanity. 
Epileptic Insanity. 
Epileptic Insanity. 
Insanity of Masturbation. 
Insanity of Pubescence. 
Climacteric Insanity. 
Ovarian and Uterine Insanity. 
Insanity of Pregnancy. 
Puerperal Insanity. 
Post-Connubial Insanity. 
Hysterical Insanity. 
Enteric Insanity. 
Limopsoitos (from starvation). 
Post-febrile Insanity. 
Insanity of Lactation. 
Insanity of Tuberculosis. 
Syphilitic Insanity. 
Cretinism. 
Delirium Tremens. 
Insanity of Alcoholism. 
Insanity from Opium-eating. 



Class III. — Sympathetic Insanity. 



Class IV. — Anoemic Insanity. . 
Class V. — Diathetic Insanity. . 

Class VI. — Toxic Insanity. 
Class VII. — Metastatic Insanity. 



{ Rheumatic. 

J Pellagrous. 

~j Metastatic Insanity, from healin< 

I long-established issues. 



of 



Examining these various schemes of classification, we find 
them to be based on one or other of three principles. Either 
they are framed according to the mental peculiarities of the 
patient, his exaltation, his depression, his imbecility ; or they 



128 CLASSIFICATION. 

point to a disorder of one or other of the portions into which 
the human mind is by some authors divided ; or, the mental 
symptoms being put entirely aside, the malady is classified 
according to its pathological cause and its relations to the 
bodily organism. Objections are easily raised to any one of 
these plans. A patient, it is said, may be melancholic one 
week and maniacal the next; therefore melancholia and 
mania are not scientific divisions. Most true is it that a 
patient may have no delusions one week, but may have so 
far advanced as to have plenty in the week following; there- 
fore it may be said that effective and ideational insanity are 
not true divisions. Then, if we take causes as our basis of 
classification, we may find two patients whose insanity springs 
from the same cause, yet they are in every shape and way 
the opposite one of another, requiring different treatment, 
differing as regards diagnosis and prognosis, the one hope- 
lessly incurable, the other bidding fair to recover. Can we 
adopt such a basis as this ? If not, what are we to look for 
to guide us in our attempt? 

It appears to me, that if we classify not the so-called forms 
points to be of insanity, but insane patients, we shall be re- 
observed. minded practically of certain points which other- 
wise we might overlook. We wish, of course, to ascertain 
for the purposes of our classification as many as possible of 
the conditions of the patients before us. If the conditions of 
any two were precisely alike, the insanity would be identi- 
cal ; but as no two people are alike, no two people's insanity 
is alike. If we have before us a dozen patients whom we 
are to classify, and we find that four of these are in an ex- 
treme state of depression, four are delirious and in a state of 
furious mania, while the remaining are gay and exalted, pre- 
senting the well-known symptoms of general paralysis, it is 
plain that there must be allied conditions existing in the 
members of each one of these groups which bring about the 
peculiar features of it, and which do not exist in the other 



CLASSIFICATION. 129 

groups. What these conditions are we cannot scientifically 
determine, but we may be sure that those which give rise to 
melancholy in a man of fifty are not the same as those which 
exist in a young man suffering from acute mania at twenty- 
five. Yet we may, according to some, group them together, 
and give to each the name of idiopathic insanity. I main- 
tain that mania or melancholia denotes a group of Themental 
conditions, most of which are unknown to us, symptoms 

cannot be dis- 

though some may be ascertainable; that in our regarded in 
scientific classification the sum-total of these con- 
ditions, which is presented to us by the whole of the symp- 
toms evinced by the patient, is not to be laid aside in favor 
of some one condition or cause, whether proximate or remote. 
As physicians engaged in the cure and treatment of insanity 
will never be able practically to lay aside the classification 
of mania and melancholia, will be forever compelled to treat 
melancholy as one thing and mania as another, so I believe 
that as pathologists they will comprehend under these general 
names a multitude of conditions which must be assumed, but 
cannot at present be demonstrated, but which year by year 
will be more and more differentiated and specialized, not by 
fixing our attention upon one, and one only, in each case, 
but by looking on every case as the result of an infinite 
number. One objection to the divisions of mania and 
melancholia is, that many patients cannot be ranged under 
either of these heads. They either hold a position midway 
between the two, so that they may be called by one mani- 
acal, by another melancholic, or they cannot be said to be 
at all maniacal or at all melancholic, their insanity being 
denoted either by a total loss of mind, such as we call de- 
mentia, or by a mere assemblage of delusions, or even by 
one delusion without emotional display of any kind. For 
this state the term monomania has been invented, but it is 
applied also to other varieties of unsoundness of mind. Now, 
with regard to the above objection, I would say that such 

9 



130 CLASSIFICATION. 

patients are for the most part chronic and incurable, present- 
ing to us the results of former attacks and pathological states. 
As the damaged valves of the heart point to a long-past 
condition of endocardiac inflammation, so the fixed delusions 
or hallucinations of an incurable monomaniac point not to a 
present but to a past pathological state. Were we always 
called upon to examine and classify patients in the very 
earliest stage of their insanity, we might possibly classify 
them according to the pathological origin of their disorder; 
but after years of alienation Ave necessarily lose sight of the 
Nor in origin and original condition, and our attention is di- 
chromc. rec ted to the mental sjmiptoms ; and for the purposes 
of treatment and safe custody we cannot ignore these. We 
are obliged practically to classify our patients as melancholic 
or maniacal, paralytic or demented. To take the illustration 
already used, we recognize as most important the distinction 
between mitral and aortic disease, yet, pathologically, we 
might say that each may spring from rheumatic endocarditis, 
and therefore the division is an accident, and not scientific. 
But it is one thing to lay down the pathological varieties of 
insanity, as I have attempted in my third and fourth lectures; 
it is another to classify insane who may be set before us in 
all stages and periods of the disorder. If we can examine 
the individual at the outset of the disorder, and thoroughly 
ascertain his history, we may be able to lay down with con- 
siderable accuracy his pathological condition. He is not yet 
in a state which warrants the name of mania or of melan- 
cholia, still less of dementia ; but his state is clearly aberra- 
tion of mind and disturbance of brain function, depending 
on some conditions or causes such as I have been describing 
to you. But as the disorder becomes more marked and sys- 
tematized, it will be found to assume one or other of certain 
forms, and to be accompanied by certain symptoms which 
have gained for it the name of mania, or melancholia, or 
acute dementia ; and as the treatment and prognosis must 



CLASSIFICATION. 131 

vary according to the symptoms, I shall pass in review some 
specimens of these different patients, that I may be enabled 
to give you some practical advice as to what you are to do 
when called upon to treat them. To classify insanity per- 
fectly, we ought to be able to connect the symptoms of exal- 
tation or depression with the pathological history of the 
individual, but this at present we cannot do. We are obliged 
to make two classifications, to lay down abstractedly a patho- 
logical classification of insanity, such as I have endeavored 
to give, and on the other hand to describe according to the 
most prominent and important symptoms the various pa- 
tients we have to protect and cure. Classifying not the dis- 
order, but patients, I would reverse the order suggested by 
the committee of the Medico-Psychological Association, and 
note in the first place the mental symptoms observable at the 
time of inspection, and afterwards assign to these their path- 
ological significance, if the history or the symptoms enable 
us to do so. As in all diseases, the immediate symptoms 
must direct the immediate treatment, though the pathology 
will also have an importance which it is hard to over-esti- 
mate. 



LECTURE VI. 

Causes of Insanity — Predisposing Causes or Tendencies— Hereditary 
Predisposition — Prognosis — Statistics — Age — Sex — Condition of 
Life — Is Insanity on the Increase? — Exciting Causes — 1. Moral — 
How to be Avoided — 2. Physical — Prevention of the Recurrence of 
Insanity. 

In my lecture on the Pathology of Insanity I pointed out 
that each case at its commencement ought to be examined 
as a whole, and all the various conditions considered, which, 
by preceding it, become the cause. These conditions are, 
some of them, extremely complex, some comparatively simple. 
They often require themselves to be resolved into simpler 
causes, and for this reason it is necessary that we should in- 
vestigate them at greater length than has been already done; 
and first I must set before you certain states, which are often 
called predisposing causes of insanity, such as sex, 

Predisposing -^ n . Z.. . .,.-.. 

causes or age, degree of civilization, inherited taint, and the 
like. It is clear that these can only be called 
causes in the sense of their beinor concurrent conditions/ of 
the individual w T ho for the time is insane. UL man in one or 
other of these states has a greater tendency to become in- 
sane, if other circumstances also tend to produce insanity in 
hirm/ The latter may be the result of a number of tendencies 
which may exist separately in others without producing any- 
thing of the kind, but which, concurring in him, are the 
cause of it ; or these tendencies may remain for years un- 
productive of evil, till some external circumstance completes 
the series, and overthrows the stability of the mind. Speak- 
ing generally, we may examine the causes of insanity under 



CAUSES OF INSANITY. 133 

the heads of tendencies, or, to use a commoner term, pre- 
disposing causes, and events, more or less accidental to the 
individual, such as are generally called moral and physical 
causes. It is not my intention to examine these various 
causes with the idea of connecting them with the patho- 
logical state of the brain in insanity. I have already con- 
sidered this, and have spoken of some from this point of 
view : I mention them now in order to make some sugges- 
tions of a practical nature. 

The first tendency which demands your attention is hered- 
itary transmission, for it is of all the most potent, 

J . r Hereditary 

and ought always to be kept in view by those aware predisposi- 
of its existence, whether medical men, parents, or 
guardians. Here is a cause of insanity which cannot be got 
rid of, a part and parcel of the individual's constitution and 
being; consequently his surroundings must be adapted to it; 
and, so far as we can, we should avert such events as are 
likely to upset his mental balance. Much may be done in 
this way if friends will only look the threatening evil in the 
face, and not try to hide it away, in the vain hope that no 
one will ever know it. 

C The first remark to be made is, that children may inherit 
insanity from parents who are not insane ; and this we can 
explain in two ways : first, although the parents may not 
have been insane, insanity may have existed in their parents 
and reappeared in the grandchildren, skipping a generation; 
secondly, though the parents may not have been insane, they 
may have been the subjects of neuroses, which in their prog- 
eny become insanity; they may have been chronic drunkards, 
epileptics, hypochondriacs, weak-minded, or have indicated 
their nervous condition by chorea, stammering, and the like. 
The reverse of this is also true : insane parents, either or 
both, may have a number of children, some insane, others 
idiots, others epileptics, deaf mutes, or nervous, and some 
perfectly sane and sound. Two laws of nature are concerned 



134 CAUSES OF INSANITY. 

in the production of these phenomena. One is, that pecu- 
liarities and abnormities are apt to recur in descendants for 
many generations ; the other, that there is always a tendency 
to return to the type of health in beings which have sufficient 
vitality to perpetuate their existence and carry on their race 
for successive generations. We could not breed an insane 
family, of which all the members should be insane for gene- 
rations. We should have sterility and extinction, or a return 
to a healthy type. Were this not so, the numbers of our 
lunatics would be tenfold what they are. We may see one 
child in a family insane, and the others sane. The one has 
inherited more of the ancestral defect than the others, but in 
the descendants of the latter the family taint may again re- 
veal itself. All these points you will have to consider if 
Advice as to y ou are consulted as to the marriage of persons of 
marriage. w hose families some member is insane. This ques- 
tion will come before you in various ways. You will be asked 
whether you can sanction the marriage of a man or a woman 
w^ho has once been insane ; also, whether you advise that of 
a person whose father, mother, brother, sister, or more distant 
relative, is or has been insane. You will be consulted on 
both sides, on behalf of the individual, and also by him or 
her who is about to enter into matrimonial relations with the 
tainted family. Here professional confidence and ethics are 
involved, and cases arise of no little difficulty. It is not easy 
to lay down any rules for your guidance. This much I may 
say, that if any one has already had an attack of insanity, 
there is always good reason for thinking that he or she will 
have another sooner or later; consequently, whoever is about 
to marry such a man or woman, ought, beyond all question, 
to be informed of the preceding, and the chances of subse- 
quent attacksj You will find, however, that such matters 
are kept profound secrets ; and not once or twice, but over 
and over again, complaints have been made to me that they 
not only were not made known to the intended, but that the 



CAUSES OF INSANITY. 135 

most flagrant falsehoods were told when the direct question 
was asked. There is also another consideration, — the pros- 
pects of the children. Where a woman has been insane, 
her insanity is so likely to recur during pregnancy, or after 
parturition, or even during the first excitement of nuptial 
intercourse, that I never could bring myself to consent to 
the marriage of such a one ; in addition, her children would 
run a great risk of being insane, nervous, epileptic, or idiots. 
A man is not exposed to so many causes of insanity as a 
woman, but his children are also liable to be affected with 
the inherited taint. Of course, if the woman is past child- 
bearing, there is far less objection to her contracting mar- 
riage. Then it is for the husband only to say whether he 
chooses to encounter the risk of marrying one who has 
already shown symptoms of the disorder. 

If we have to consider the marriage of persons who have 
never themselves shown any signs of derangement, but 
whose parents, or brothers, or sisters, have been, or are, 
insane, we have a much more complicated problem to solve. 
Much must here depend on the number of individuals in a 
family who have been, or are, insane. I have known a 
family in which, out of nine sons and daughters, six have 
shown unmistakable signs of mental disturbance : marriage 
with any one of these children should certainly be avoided. 
But we may see other families in which perhaps one member 
is insane and the rest perfectly sound. In this case we can 
only argue in view of the particular individual. I know 
brothers of insane men and women who are, in my opinion, 
as little likely to become insane as any of my acquaintance, 
but the transmitted taint may crop out in some of their chil- 
dren, even if the majority escape. I would not go the length 
of forbidding every one to marry who had an insane relative, 
for the number thus barred would be immense ; but it must 
be considered that there is a certain element of risk, and 
this at any rate should be clearly set before the person who 



136 CAUSES OF INSANITY. 

is thinking of entering into the union. And the risk is 
greater where either of the parents has been insane than 
where brothers or sisters have ; also, it is greater for girls 
than for men, for obvious reasons ; also, it is greater for a 
brother who has an insane brother, than for one who has an 
insane sister ; and conversely, an insane sister increases the 
risk of a girl more than an insane brother. It is, I believe, 
a fact borne out by statistics, that daughters inherit insanity 
from an insane mother in greater proportion than sons, and 
in the same ratio sons inherit it from an insane father. The 
risk, therefore, to a daughter or son would be determined to 
some extent by the sex of an insane parent. I said that 
peculiarities are apt to return in descendants through many 
generations. The chance, however, of their appearing in 
any one individual, is lessened in proportion to his distance 
from the diseased ancestor. Insanity is most frequently de- 
rived from parents, but it may come from grandparents, 
great-grandparents, or progenitors even more remote. When 
it comes from grandparents, it is called atavic, and is 

Atavism. . . 

said to have skipped a generation. Inis is nothing 
but an instance of a defect reappearing at a longer interval 
than the first generation, and is only a variety of the general 
law. For we often find that although some one or more of 
the children may escape, yet others will show signs of in- 
sanity or other neuroses. If the descendants of these healthy 
children are affected, we may call it atavism, but the disorder 
cannot be truly said to have missed a generation if uncles 
and aunts were affected. I do not believe that we ever find 
a number of children of insane parents all entirely exempt 
from insanity or allied disorders, which afterwards are mani- 
fested in the grandchildren, the intermediate generation 
being completely unscathed. The fact is, that we have very 
imperfect data on which to base our laws of heredity. The 
paupers who come to our county asylums know little of the 
history of their family beyond their nearest of kin ; the well- 



CAUSES OF INSANITY. 137 

to-do portion of the community deny the existence of hered- 
itary insanity in their families in a way which must be heard 
to be believed ; and as nothing is called insanity but that 
which necessitates incarceration in an asylum, and as other 
neuroses are disregarded altogether, it is clear that our infor- 
mation is valueless. You may, possibly, some day be able to 
follow the fortunes of a family in which insanity is mani- 
fested for two or three generations. A carefully recorded 
history of such a one would be of the highest value. 

I have said that among the descendants of insane patients 
there is the tendency to revert to the healthy type, Hereditary 
this being effected by the introduction of vigorous insaDit > r 

<-> *s <~> terminated 

germs from other stocks, while a certain portion, not mtwowaya. 
healthy enough for this, descends by gradual stages to ster- 
ility, idiocy, and extinction. Hence two things : first, we 
are not likely to have to look back very many generations 
to find the source of the inherited disease ; secondly, it fol- 
lows that people must be continually contracting that which 
becomes in their descendants hereditary insanity — for hered- 
itary insanity is not an entity to be acquired and transmitted 
pej'^z^J It must itself have had a cause and a beginning, and 
this we shall have to seek among the pathological causes and 
conditions of nervous disorders. 

If we have the opportunity of knowing and observing all 
the children in a family tainted with insanity, it will not be 
difficult to point out, even at an early age, those individuals 
in which it is most likely to be developed. Children may 
show signs of a nervous temperament almost from birth. 
Convulsive attacks, night horrors, a tendency to spasmodic 
ailments, chorea, or epilepsy, mark out those who inherit, 
beyond others, the hereditary weakness. These we should 
specially guard : their future and their external surroundings 
must be regulated so as to preserve them from too great re- 
sponsibilities, too continuous labor, too sudden changes of 
fortune. We must, so far as is possible, create their circum- 



138 causes or insanity. 

stances, and not leave them to be the creatures of circum- 
stance entirely beyond their control. Although we cannot 
guarantee any one against becoming insane, Ave can point to 
those most threatened, and it may be necessary for such, if 
they be women, to pass through life without encountering 
the perils of childbearing. 

But, besides this, there is another practical point in con- 
nection with the question of hereditary insanity. 

Prognosis. . . J 

When we are called to an insane patient, and are 
told that there is insanity in the family, how will the infor- 
mation affect our prognosis? Many persons think that a 
patient has no chance of recovery if the disorder is inherited. 
Is this so ? I have found in my own experience that those 
affected by inherited insanity recover, at any rate in the first 
attack, quite as often as others. Being unstable by nature 
and constitution, they are thrown off their balance by some- 
thing that is often trifling and removable, and often there 
may be no assignable cause. So by dint of seclusion and 
quiet they regain their former equilibrium, probably to again 
break down at some future timej Such people, as you may 
conceive, recover more surely than those who have brought 
on insanity by years of alcoholism, or syphilis, or sexual 
excess. And possibly for the same reasons the death-rate is 
less in them, at any rate in the first attack. There is un- 
questionably a tendency to subsequent recurrence of the 
malady, but this exists in all who have been insane, what- 
ever may have been the cause. 

Statistics on the subject are valueless. One author attrib- 
utes 10 per cent, of cases to this cause, another no 

Statistics. 

less than 90. This arises from lack of information 
on the part of some friends, and the wilful concealment of 
others, and also because some statisticians seek for insanity 
only, taking no account of other neuroses, such as epilepsy 
or paralysis. If we make the attempt, we shall soon find 
how difficult it is to get an accurate account of the health of 



CAUSES OF INSANITY. 139 

the father and mother, and grandfather and grandmother of 
any one patient. 

As insanity may be engendered of nervous disorders of 
other kinds in the parents, or as the parents' insanity may 
appear as the child's chorea, so may insanity of one kind in 
the parent reappear as insanity of another kind in the chil- 
dren ; in fact, the latter may represent every variety of the 
disorder. As I have already said, the particular character 
of it, the mania or the melancholia, depends on the consti- 
tutional strength or weakness of the individual at the time 
of the outbreak, and the same person may be at the one time 
maniacal, at another melancholic. It is true that we fre- 
quently see the same form in successive generations, e. g., 
suicidal melancholia or hereditary drunkenness, but this can 
only be looked upon as a coincidence, if we consider the vast 
number of cases where the form is different, and where 
various children are variously affected. 

The tendency to become insane is greater or less accord- 
ing to the age of the individual, and the character of 
the insanity is also determined to a considerable extent 
by this. We find insanity, it is true, at all ages, but in the 
first decade of life it is rare. In the second it is more fre- 
quent; the mind developing, the child is growing into the 
man or the woman, and is acquiring knowledge, and is 
"looking before and after." But the next decade produces 
even more cases, and the period between twenty-five and 
forty years is that in which the number attains its maxi- 
mum ; this we recognize as the time of highest development, 
the prime of vigor, the height and climax of all hope and 
forward-looking, the time when strength is strained to the 
utmost in the battle of life. After this, in each successive 
decade, the number declines, just as in youth it rose. 

According to the time of life, variations in the nature of 
the insanity are observable. In childhood, we find it dis- 
played in violence of temper and act, in irregular and par- 



140 CAUSES OF INSANITY. 

oxysmal attacks, often of a convulsive character, alternating 
with cataleptoid states, recalling to our minds the choreic and 
convulsive condition of other children. The mental symp- 
toms are not those of the fully-developed mind — delusions, 
but perverted feelings, hatred of relatives, wanton and in- 
decent behavior, cruelty and destructiveness, and hallucina- 
tions of the senses — such as we often witness in the dreams 
and nightmares of the young. After puberty, we may find 
more of the ordinary insanity of adult life ; but this will be 
generally attended with violence and mania rather than by 
depression. Of fifty-seven boys and girls admitted during 
five years into St. Luke's Hospital, all of whom were below 
the age of twenty, only eight were melancholic. Between 
the ages of twenty and forty we meet with violent and acute 
mania and acute delirium. This is especially the period at 
which we should expect these forms of insanity. Later in 
life, in the time of waning strength and declining vigor, both 
bodily and mental, we find melancholia prevail. Fear and 
religious despondency constantly accompany the weakened 
nervous condition of the old, while later still we see the 
mental faculties giving way, and dementia and vacuity, 
rather than insanity, come over the sufferer as he sinks into 
second childishness and mere oblivion. 

These are. speaking generally, the forms we meet with at 
each epoch of life, but exceptions to them are not unfrequent. 
We may find melancholia in youth and early manhood; we 
may meet with acute delirium in patients past their climac- 
teric. And when we do, the prognosis is bad; in the latter 
case especially. I have found melancholia in the young far 
more difficult to eradicate than mania. It is generally pro- 
longed, even if recovery takes place at last. Melancholia 
after parturition is often extremely obstinate, and yields with 
difficulty to remedies. 

What has the sex of the patient to do with the chance of 
insanity showing itself? Do more men or women become 



CAUSES OF INSANITY. 141 

insane? Here authors differ, and statistics mislead. The 
records of various countries would seem to show that 
in some more males become insane, in others more fe- 
males. Into the figures and tables, and the many fallacies to 
be eliminated, I will not enter. In countries where the males 
predominate in the asylums, it is said that this is due to the 
fact that females are more easily managed at home, and 
therefore not sent so often to the asylum. On the other 
hand, the preponderance of females in our own asylums is 
explained by the lesser mortality among them, whereby they 
live a long time, swelling the lists of those in confinement. 
My own opinion is, that we have no accurate statistics on 
this point, for only those relating to new cases are of value. 
The comparative numbers of patients under confinement at 
a given time must necessarily be influenced by a variety of 
circumstances. In the Report of the year 1868, the Com- 
missioners give, as the number of the inhabitants of asylums 
and hospitals in England, 33G3 private male patients, and 
2489 private female; while of paupers there were 12,371 
males, and 14,990 females. I explain this discrepancy in 
this way : more males become insane than females, but die 
in much larger proportion, consequently the number of 
pauper females goes on increasing from the accumulation of 
chronic cases. In the well-to-do classes, however, so many 
females are kept at home that the male population of asy- 
lums predominates. The deaths during the same year, 1868, 
in asylums and hospitals, w T ere 1876 males and 1489 females; 
and this is probably about the usual proportion in which the 
sexes die while insane. 

Probably the difference in the number of the two sexes 
who become insane is not very material, but I think the 
males must be the larger body; otherwise, considering the 
mortality, they would Ml below the number of the females 
further than they do'. It might be thought that females are 
more likely to become insane, inasmuch as they are mani- 



142 CAUSES OF INSANITY. 

festly more prone to many nervous disorders, — to chorea, 
hysteria, and allied neuroses. Yet, for all this, they are 
much less prone to serious brain disease. Men are the chief 
sufferers from apoplexy, hemiplegia, softening, and the like ; 
and among the insane we find general paralysis attacking at 
least ten men for one woman, and among women of the 
higher classes it is quite unknown. It is this fatal form 
which swells the mortality of the male insane; and it has 
been said that, if we except the deaths from general pa- 
ralysis, more women die than men. But I turn to the statis- 
tics of St. Luke's Hospital, where only curable cases are 
admitted, and where no paralytics are kept to die : out of 
7311 males and 10,778 females admitted, 808 males died, 
and only 573 females, i. e., double the proportion of males. 

Among the so-called predisposing causes of insanity are 
condition ranked the condition of life of the patient, and the 
ofMe. degree of civilization. Are civilized nations more 
prone to insanity than barbarous ? Are the poor more affected 
by it than the rich ? The single than the married ? Here 
is a field for much speculation, profitable, however, to the 
philanthropist and the philosopher, rather than to the prac- 
tical physician ; for it is obvious that when we discuss the 
chances of a poor man or a rich man becoming insane, we 
take into consideration the whole surroundings of the indi^ 
vidual and his ancestors, and include in our survey circum- 
stances that are entirely beyond the reach of the physician. 
It is equivalent to inquiring whether education or its absence 
tends towards insanity, or good food or scanty, or hard work 
or little work, or head-work or hand-work. Though of little 
practical value, inasmuch as there must ever be poor and rich, 
yet the question is interesting, and when rightly considered 
and compared with carefully scrutinized statistics, it is valu- 
able in its bearings on the general history of our country. 

And first with regard to civilization : of this we may say 
sit once, almost from a priori consideration, that it tends to 



CAUSES OF INSANITY. 143 

the production of insanity. The life of civilized man is a 
highly specialized and complex life ; the variations of its sur- 
roundings are endless, and it requires to be adjusted to these 
unceasingly. And as is the life so must be the brain : the 
brain of the savage is a simple structure compared with our 
own, as the whole organism of one of the lower animals is 
simple, compared with the complex human system. _To say 
that our specialized and complex brain is more apt to be dis- 7 ' 
ordered than that of lower men, is no more than saying that 
a compound piece of mechanism is more likely to get out of 
order than a simple oneA Nevertheless, it is also true that 
bnuch of the insanity of civilization might be prevented! It 
grows out of the evils and vices of civilization, just as fevers 
and such like disorders are engendered by the crowding of 
populations. Although it must always be that the hard- 
working brain of civilized man is more prone to disorder than 
that of the childlike savage of the wilderness, yet it is to be 
hoped that the preventible sources of insanity may be by de- 
grees diminished, just as sanitary knowledge and laws will 
reduce the mortality from fevers, scarlatina, small-pox, and 
the like. 

If we compare civilized with uncivilized countries by means 
of the statistics of insanity, we shall labor in vain. We have 
enough to do rightly to examine the statistics of our own 
countrv. There are not half-a-dozen other countries in the 
world, civilized or uncivilized, whose statistics are compara- 
ble w T ith our own. In the year 1844, there were in the asy- 
lums of England and Wales 11,272 lunatics, and in work- 
houses and private dwellings, 9339. In 1858, there were in 
asylums 22,184; in workhouses, &c, 13,163. In 1868, in 
asylums 32,605; in workhouses, &c, 17,513. That is, the 
registered lunatics of England and Wales, who in 1844 num- 
bered 20,611, in 1868 reach the total of 50,118. These 
figures include the whole lunatic population, private and 
pauper; but if w r e look at the statistics of the private patients 



144 CAUSES OF INSANITY. 

only, we find that in 1858 these numbered 4612, and in 1868, 
5244, being an increase of only 632, while the total of the 
lunatics of 1868 exceeds that of 1858 by 14,771. 

We are told, however, that insanity is not on the increase, 
is insanity on that these larger numbers are the result of the 
the increase? sending to asylums patients, especially paupers, 
who formerly were kept at home, and of more stringent leg- 
islation as regards private patients, also of the prolonged life 
of those who are cared for in the comfortable asylums of Eng- 
land. The last is probably the most valid reason ; as for the 
first, pauper lunatics cannot be kept at home long; a few 
idiots and naturals may run about a village ; as they used to 
do, so do they now. But in 1844 pauper lunatics were sent 
to workhouses, if not to asylums, and so were registered. If, 
however, we examine, not the numbers of patients remaining 
in asylums, but the numbers of those admitted in each year, 
we find that the increase is not so startling, that the average 
annual increase of admissions in the nine years, 1858-1867, 
was only three per cent. That lunacy is not on the increase 
among the upper classes is, I think, quite proved by these 
statistics; for with the present very stringent administration 
of the law, the increase of 632 private patients is extremely 
small, considering the increase of population. It is doubtful, 
however, whether the increase of the number of pauper luna- 
tics can be looked upon as normal, and in proportion to the 
population. My own opinion is that among the lower classes 
of our countrymen insanity is on the increase : let us see if 
we can discover any sources of the disease existing among 
them, to which the richer portion of the community is less 
exposed. One thing we may at once observe : there is a de- 
gree of drunkenness among the lower classes of this country 
which is not to be found in the higher. Those who read the 
accounts of the habits and customs of the richer classes at 
the close of the last and the beginning of the present century 
must be aware that the gentlemen of our own day are, as re- 



CAUSES OF INSANITY. 145 

gards temperance, entirely different from our grandfathers, 
with whom intemperance was the rule rather than the excep- 
tion. It cannot but be that amongst these classes the chil- 
dren of our own times must benefit largely in all that concerns 
their nervous condition by this change in their parents' life. 
But it is to be feared that our lower orders are in no degree 
reformed in the matter of drink. Notwithstanding the exer- 
tions of temperance societies, the amount of drunkenness still 
prevalent is enormous, and is almost confined to the lower 
orders — the working men — below the shopkeeper class. 
Making all allowance for the highly-colored pictures drawn 
by the advocates of total abstinence, it is probable that in- 
temperance is on the increase rather than decreasing. Hence, 
I believe, springs the ever-renewed insanity of our lower 
classes. For as insanity has a tendency to die out like other 
diseases — to cause the extinction of a race, or itself to be 
overcome by the greater vigor of some of the stock — it is clear 
that the enormous insane population of our country must 
owe its insanity to ever-present causes, — it cannot all have 
been inherited from our great-grandfathers. Andjtf we could 
accurately ascertain the statistics of insanity in other coun- 
tries, civilized, semi-civilized, or barbarous, I think it is prob- 
able that we should find insanity in proportion to the use of 
intoxicating liquors or substances^ Secondly, poverty itself 
bears a part in the causation of insanity. The poorest coun- 
ties in England contribute the largest numbers to their re- 
spective asjdums. According to the returns, Dr. Thurnam 
tells us Wiltshire stands in the unenviable position of having 
a greater proportion of insane paupers than any other county 
of England and Wales. Those most nearly approaching it 
are Gloucester, Oxford, Berks, and Dorset — all agricultural 
counties. According to the poor-law returns, Wiltshire has 
a larger proportion of pauperism than any other county — viz., 
1 in 12; the next in order being Dorset, Oxford, Gloucester, 
Berks, and Hereford. 

10 



146 CAUSES OF INSANITY. 

UEhe fact that in Ireland, with a decreasing population, we 
find an increase in the numbers of the insane, may aid us 
somewhat in discussing the causes of insanity Here we 
have no keen encounter for success in the battle of life, no 
overwhelming business, or speculation, or accumulation of 
wealth ; all is on the decline : poverty, ignorance, and fanat- 
icism, and withal drink, are the chief pauses to which we 
must ascribe the increase of insanity. tEhat' the poor must 
be more prone to become insane than the rich, is consistent 
with the pathology of the disorder. Insufficient food is an 
acknowledged source of defect in the nerve-power^ and with 
this there must be the concomitant anxiety, the care for 
to-morrow, the spectacle of the family stinted of the neces- 
saries of life, and want of early medical advice and treat- 
ment. Poverty of this kind must weigh heavily on the 
mind. When we say that the poor are more disposed to 
insanity, we virtually mean the poor in any class of life. 
There may be well-to-do people in all ranks of life, who, 
although they would not be classed among the rich, do not 
suffer from poverty. Amongst these well-to-do folks of the 
artisan class the great causes of insanity are, first, the want 
of education, which leads to the second, drink. Whether 
either the one or the other of these can be diminished by 
legislation is one of the questions of the age. If we could 
lessen drunkenness, we might close some of our asylums; till 
we do this we shall have to enlarge them. 

I have thus glanced at some of what are called the pre- 
Excitmg disposing causes of insanity, which are in truth the 
causes. conditions of certain classes of the community, and 
can only in a sense be considered causes. But there are 
others, special to the individual, which are called exciting 
causes, and whether preventible or not, frequently bring 
about the particular attack of insanity. Of many of these 
I have already spoken in discussing the pathology of the 
disorder, but some few words still remain to be said. 



CAUSES OF INSANITY. 147 

In speaking of one section of these exciting causes — namely, 
the moral or jpsycliical — I divided them into those 

,., i-i-iii • jii Moral causes. 

which operated suddenly, causing a great shock or 
fright, and those which produced insanity by anxiety or 
worry spread over many years. Of these, the former, I 
think, is more frequently the active agent in the causation 
of insanity. A sudden calamity, loss of a dearly-loved relative 
or friend, reverse of fortune, political catastrophe, or a shock or 
fright proceeding from some awful spectacle or violent quar- 
rel, or near approach to death — these are the things which 
unhinge the mind, throw it from its balance, and may render 
even a tolerably strong-minded person incapable of taking care 
of himself for a time. The causes that operate, not suddenly, 
but slowly, may produce insanity, or other brain disease, the 
result of over-fatigue and work. The brain becomes worn out, 
and "softening" and such like conditions are the result. 

The pathological causation of insanity I have not here to 
consider. When I speak of the causes, it is with the view of 
examining into such matters as may be prevented, or taken 
away from those who are insane or threatened with insanity. 
For it is certain that psychical causes preponderate in the 
production of insanity, because the persons who most fre- 
quently become insane are they who are strongly predisposed 
thereto, and are easily thrown off their balance by mental 
influences. Those who are perfectly free from all predis- 
position and taint do not become insane from losses, worry, 
or work. They suffer, and are strong; they buffet vigorously 
the waves of adverse fortune, and when the malevolent tide 
again ebbs, they are none the worse for the contest. But it 
behooves us to counsel and advise those, or the friends of 
those, who by hereditary taint or previous attacks How t0 be 
of insanity are predisposed and liable to its invasion, avoided - 
to avoid to the utmost all that is likely to cause uncertainty, 
harass, or reverses in their daily life. There is much, of 
course, that no one can foresee, avoid, or escape. Health of 



148 CAUSES OF INSANITY. 

self or family is a matter of uncertainty. Accidents may 
happen to wife or children, shocking sights may occur, but, 
nevertheless, in the choice of employment, and method and 
rule of life, much may be done to avoid that which is to some 
a fertile cause of insanity. Supposing we have to deal with 
a young man, whose parents, or brothers, or sisters have been 
insane, or who at an early age has shown that he is himself 
not free from the family taint — and insanity in the young is, 
as I have said, almost invariably due to hereditary influences 
— we should advise that such a one should be put to some 
occupation or calling not attended by any great harass or 
responsibility, one of which the duties and work are of a 
routine character, affording a fair opportunity of holiday and 
recreation. Sjje should not follow the profession of a lawyer 
or a doctor, for in them he will find hard and constant work^ 
heavy responsibility, and the necessity of appearing in pub- 
lic; /and his work and anxieties will follow him to his fire- 
side and hours of sleep. In the church he will or may be 
assailed by religious doubts,tby a sense of duties insufficiently 
discharged, and by all thatftends to religious melancholy. Uln 
the army he will be exposed to the temptations of an idle 
life, and the vicissitudes of climate. No post is so suited to 
these individuals as that of a government office. The hours 
are light, the responsibility is not formidable, the holidays 
are long, and if the emolument is not large, it is at any rate 
certain, and certainty is above everything desirablei For the 
latter reason Ithe property of such persons should not consist 
of doubtful or speculative investments, which may expose 
them to great anxiety or possible ruinjj but they should be 
induced, even at a loss of income, to place their capital in 
solid and sure securities. Many anxieties and worries which 
are every day occurring, might certainly be avoided by a 
little prudence and forethought. 

vXt is no doubt of immense service to many such men that 
they should be happily married at an early agel The ten- 



CAUSES OF INSANITY. 149 

dency to eccentricity and a solitary life is thereby counter- 
acted, as well as other habits or vices. But everything will 
depend upon their finding wives who will be truly helpmeets 
to them. Doctors can only speak in the most general terms 
on such a subject; bat it is right that parents and guardians 
should put a stop so far as they can to the growing attach- 
ments of a couple in no way fitted for each other. The w r ife 
of such a man should be healthy, one who will not cause 
him constant anxiety, broken nights, or the expense attend- 
ant upon bad health, who will not breed sickly children to 
fade and die, or to grow up a perpetual misery to their pa- 
rents; and, above all, she should not be a relation. 

If the object of our solicitude is a girl, what can we do to 
keep her from harm ? The first question is, shall she marry ? 
Here I would say that no girl who has ever shown any 
symptoms of actual insanity ought ever to marry at all. 
Insanity is not the less likely to return because the attack 
has been transitory. If it has come on at an early age with- 
out assignable cause, it is because it is inherited, and it is 
very likely to reappear during pregnancy or after childbirth. 

But if there have been no symptoms in the girl herself, 
but she comes of parents, one or both of whom have been 
insane, or if she has brothers or sisters insane, what are we 
to say ? We must be guided by what we know and see of 
her, by her physique, her history, especially the history of 
her infancy, the absence or presence of " fits," of " nervous- 
ness," " hysteria," habitual sleeplessness, or irritability, espe- 
cially at the catamenial time. If a girl who is predisposed 
to insanity does marry, it is important that she should not 
marry a poor man, whose life will be a constant struggle for 
existence ; nor a sickly man, whom she must always nurse ; 
nor one whom she must follow to tropic climates ; nor one 
who is violent, irritable, or jealous. If she is obliged to do 
something for her livelihood, and does not marry, her work 
should, if possible, be free from heavy responsibility. It is 



150 CAUSES OF INSANITY. 

obvious that we shall have very little to do with the arrang- 
ing of all this. If we express our opinion, we often say our 
say, and say it in vain. And yet it is well to turn such sub- 
jects over in our minds, and to be ready with an opinion upon 
them. What I have said applies to the rich rather than the 
poor : it is about the rich and not the poor that we shall be 
consulted. 

The physical causes of insanity are in many cases beyond 
physical prevention. We can only deal with them as they 
causes. arise. They may be the sequel of other disorders, or 
accidents, or may be due to the time of life. 

Insanity, the result of alcohol, opium, or haschisch, is no 
doubt preventable ; but we have to deal with acquired habits 
in the majority of instances when brought into contact with 
persons who take these substances. When we have the op- 
portunity of supervising the management of those predisposed 
to insanity, it is important to check at the outset that which 
may grow to be a habit hard to be abandoned. First and 
foremost they must be watched while children, lest they give 
themselves up to masturbation, for they will carry it to ex- 
cess, and will be the least likely to abandon it, if it be once 
confirmed — a truth which applies equally to girls and boys. 
Early habits of drinking also are frequently contracted by 
weak-minded people, both males and females ; and we con- 
stantly find that habitual drunkards, as well as dipso-maniacs, 
are the offspring of insane or epileptic parents. We must be 
careful lest we encourage a love of drink in "nervous" people, 
especially women, by an incautious administration of stimu- 
lants for the cure of hysterical, hypochondriacal, or neuralgic 
symptoms. 

That which I believe to be the most common cause of 
general paralysis of the insane, viz., sexual excess, is a matter 
over which we have very little control. The disease does 
not commence in boyhood, rarely before the age of twenty- 
five. It occurs as often amongst married men as amongst 



CAUSES OF INSANITY. 151 

single, and frequently until it shows its presence there is 
nothing to call for warning. Such warnings are rarely 
heeded, but it may be in our power to give them to many, 
both husbands and wives, for general paralysis is not the 
only ill that springs from unrestrained sexual intercourse. 

In considering the causes of insanity, we shall have to 
bear in mind not only the prevention of insanity „ 

•> ■*• J Prevention of 

in a patient who has never been insane, but also the return of 

. p . . insanity. 

the prevention of its recurrence in one who has 
had an attack. Here our difficulties will be in some respects 
greater, in others less. The same cause of worry or grief 
may not occur again, or may be removed or counteracted ; 
the same bodily illness, as fever or measles, may not recur. 
Attention to the health, to diet and regimen, may remove 
some causes — syphilis may be eradicated, drink avoided. 
But, on the other hand, we have the fact to contend with, 
that insanity has really existed in the individual, and beyond 
all question has a tendency to recur either upon a very slight 
cause, or without any assignable cause whatever. This it is 
which makes it so hazardous a thing to marry a man or 
woman who has ever shown any symptoms of the disorder. 
When a patient leaves an asylum, we are generally asked 
what is to be done ? what is to be guarded against ? and our 
answers are for the most part very general : avoid hard work, 
all that calls for great emotional exhaustion, avoid disappoint- 
ment. This may seem foolish counsel, but those who cannot 
bear disappointment should not encounter it. How many 
do we see aspiring to that to which they can never attain, 
trying for appointments and the prizes of life which are 
utterly out of their reach ! Quiet and contentment are the 
qualities which favor health of mind, but it is not for us to 
give these to the restless spirit of a patient saturated with 
insanity. 

j Men and women become insane, because it is in their 
nature and constitution to develop insanity, and when we 



152 CAUSES OF INSANITY. 

hear that this or that has caused their insanity, it is often 
their restless and half-crazy brain that has made mountains 
out of molehills, and given an objective existence to troubles 
and vexations which exist in their minds subjectively, and 
have no outward reality whatever. I 



LECTURE VII. 

The Symptoms of Insanit}' — The False Beliefs of the Insane — Defini- 
tions of Terms — Delusions — Their Rise — Varieties — Hallucinations 
— Their Seat — Hallucinations of Sight — Hearing — Smell — Taste — 
Touch. 

Having hitherto spoken to you of the disease termed in- 
sanity, and the pathological condition of an insane man, I 
now proceed to consider the symptoms, the things which 
insane people do and say, by which we judge them to be of 
unsound mind. Many acts and many ideas at once reveal 
the state of the mind, though there may be no fixed line of 
demarcation between acts or ideas, sane and insane. 

If we take, first, the beliefs of insane persons, we shall 
have to examine the meaning of certain words met with in 
treatises on the subject. These are delusions, illusions, and 
hallucinations — words used by different authors in various 
senses, with some of which, at any rate, you must be 
acquainted. 

A delusion is a false belief in some fact which, generally 
speaking, personally concerns the patient, of the Definition of 
falsity of which he cannot be persuaded, either by DeIusion - 
his own knowledge and experience, by the evidence of his 
senses, or by the demonstrations and declarations of others. 
A man thinks his head is made of brass, that he has a fire 
in his inside, that he is a beggar or a prince; and no amount 
of proof convinces him of the contrary. 

Hallucinations are false perceptions of the senses, the eye, 
the ear, the nose, and so on. The hallucinated patient 
thinks that he sees in the blackest darkness, or Definition of Hai- 
hears a voice through any number of thick walls, 



lucination. 



154 THE FALSE BELIEFS OF THE INSANE. 

whereas his seeing or hearing is entirely subjective, taking 
place altogether within his own head without any excitation 
conveyed to his organs from the outer world — when, in fact, 
he would hear and see the same were he deaf or blind. 

An illusion is also a false perception of the senses, or rather 
Definition of a mistaken perception. There is something to see 
illusion. an( ^ something to hear; but that which the patient 
thinks he sees is not the real thing, but something else. He 
sees a chariot in the sky, when every other person sees a 
cloud ; he hears a voice, when others hear the noise of a 
carriage or a distant footfall. 

Such are, I believe, the commonly received meanings of 
these words, but such interpretations are necessarily arbitrary. 
And by some the word illusion is used as synonymous with 
delusion. Prichard, in his well-known work, nowhere speaks 
of delusions, biit uses illusion instead. 

There are various questions which arise in connection with 
these fancies of the insane — e. g , how do delusions and hal- 
lucinations arise ? what is the relation between delusions and 
hallucinations? what is their significance in the diagnosis 
and prognosis of insanity ? 

We know too little of the physiology of the brain to be 
able to put our finger on the seat of an hallucination ; we can 
only approach the study thereof by comparing analogous 
phenomena in healthy people, or in people not insane, and 
by contrasting the delusions and hallucinations of one insane 
person with those of another. 

Hallucinations bear to delusions the same relation that the 
Relation of simple perception of objects does to judgment and 
haiiucina- reasoning founded on the perception, and both hal- 

tions to delu- ° L L 

sions. lucinations and delusions illustrate the growth of 

ideas and intellect in the mind. For, as I have said already, 
sensations, the stimulation of the organs of sense and the 
resulting feelings, and also the feelings experienced by the 
organism generally, whether of pleasure or pain, are the or- 



THE FALSE BELIEFS OF THE INSANE. 155 

igin and material out of Avhich ideas and intellect are devel- 
oped. These simple sensations, as they are linked together 
by memory, grow into complex ideas and complex feelings — 
feelings which we term emotions — but at the root of all are 
the bodily sensations caused originally in the majority of 
instances by stimulations coming from without, at any rate 
from without the cerebrum. 

It would appear that delusions and hallucinations are 
false interpretations of morbid feelings and sensations Rise0 f 
occurring in various parts of the system, the falsity delusions - 
of which the disordered brain is not able to appreciate. In 
the case of delusions this is not difficult to trace. And thus 
we can explain how it is that the delusion of the insane man 
almost always refers to himself. Many sane persons believe 
in absurdities of all kinds — in charms, in witches, in ghosts, 
spirit-rapping, and the like — yet they may hold such beliefs 
without ever having seen or been concerned with any of 
these things. They entertain a mere abstract belief in them. 
But the delusions of the insane man have reference to him- 
self, just as in dreams we are always present and see and 
hear what is going on : we do not dream abstract notions or 
facts which wholly concern others, in which we do not in 
some way participate. 

Delusions are not the first indications of a change in the 
mental condition of the patient. This fact is important as 
regards both the pathology and also the legal diagnosis of 
insanity. The changed feeling may express itself in de- 
pressed manner, in unusual excitement, anger, restlessness, 
or in acts of an extraordinary or outrageous nature, without 
being translated at any time into what we know as delusions; 
and these when noticed have been usually preceded by a 
period of alteration, which may or not have attracted 
attention. 

There is, as I have already said, an acute stage at the 
commencement of every case of insanity, though you may 



156 THE FALSE BELIEFS OF THE INSANE. 

not see the patient during its continuance. But as insanity 
implies a deviation from the normal mental condition of the 
individual, so it connotes a physical disturbance of the brain- 
function, with impaired sleep, possibly pain, heat of head, 
flushed or pale face, suffusion of eyes, throbbing of carotids, 
and such like symptoms of cerebral disorder. This is the 
period of emotional alteration visible to others, of which the 
patient himself may or may not be conscious. 

In the majority of instances this change is one which 
makes the patient feel or think that something is amiss with 
him, as in truth there is. His consciousness, however, of 
something being wrong with his head or his s} T stem generally, 
will vary much. He may be quite aware of it, and may seek 
advice and assistance like any other patient. He is more 
likely to be unconscious of his real condition, and to attribute 
the feeling he experiences to external causes. According to 
the feeling, its degree and intensity, will be the nature of the 
cause to which it is ascribed, and the means taken to get rid 
of it. 

The defective condition of brain operates in two ways. 
First, the lack of nervous energy brings about the feeling of 
there being something wrong, and this may vary immensely 
in degree ; secondly, the disorder in the various portions of 
the brain reduces it to such a state that the patient is unable 
to see the absurdity or impossibility of the explanations which 
he gives. 

A man or woman feeling great depression of spirits pro- 
Gioomy ceeds to account for it according to his or her views, 
delusions. Q ne thinks beggary the greatest evil that can befall 
him, and straightway fancies himself ruined, his wife and 
children starving, and the officers at the door to hale him to 
prison. So imperfect is the action of his entire brain, that 
he fails to assure himself from actual inspection of his ac- 
counts that everything is going on as usual. Another looks 
not at the things of this life, but at those of the future. His 



THE FALSE BELIEFS OF THE INSANE. 157 

soul is lost, he is in the power of the Evil One, he is Satan 
himself, or Antichrist — there is no hope for him. And inas- 
much as the feeling experienced is strange, unaccountable, 
mysterious, patients fly to the mysterious for the cause thereof. 
It is due to mesmerism, to electricity, to secret and loathsome 
disease hidden in the flesh and bones, destrojang heart, stom- 
ach, and bowels, though not to be discerned outwardly. The 
ignorant man will think it due to witchcraft or the devil. 
According to his stores of knowledge, his education, and ex- 
perience, each will invent a cause for that peculiar condition 
of which he is aware, but which he cannot rightly explain. 
Having no ideas connected with this feeling, he expresses it 
in those habitually associated with a feeling of deep gloom, 
anxiety, or displeasure. Feeling himself peculiar and changed, 
and another man, he thinks that all men are looking at him, 
pointing at him, deriding him. The cabmen and omnibus- 
men beckon to and mock him ; the passers-by avoid him. 
And in the same way all the newspapers write about him ; 
all the mysterious advertisements refer to him. If he cannot 
fix his annoyances on any one he knows, he thinks bands of 
unknown conspirators are plotting against him, and that these 
can, by occult and supernatural means, affect him, even when 
far distant. Then, as he feels discomfort in this or that part 
of his body, he says his head is of brass, or he is galvanized, 
or his inside burnt with fire. With all or some of these de- 
lusions he may vary greatly in his emotional display, being 
profoundly dejected and in a state of melancholia, or being 
irritated or angry, and inclined to act on the offensive, when 
we call his affection mania. And yet he may be equally 
melancholic and equally maniacal without his ideas being 
perverted into delusions, though they will be tinged with his 
prevailing feeling. Similarly, his delusions will range from 
possibilities, or even probabilities that require some examina- 
tion before they can be pronounced delusions, up to the wild- 
est absurdities and the most incoherent nonsense that a mad- 



158 THE FALSE BELIEFS OF THE INSANE. 

man can utter. The latter are indications of a much greater 
brain-disturbance, a greater disconnecting of the relations of 
the various portions of the brain, and impairment of the brain- 
force and brain-circulation ; but the prognosis is not always 
on this account more unfavorable. They bear the same re- 
lation to the possible delusions that the dreams and night- 
mares of the fever patient do to the natural dreams of the 
healthy sleeper. 

There is a proneness on the part of most people to seek 
cause as- an d assign a cause for all ailments, and for every- 
signed for thing which is new, abnormal, or of which the origin 

the altered . . 

feeling. i s not plainly visible. Every one can tell us exactly 
where he caught his catarrh, what caused his diarrhoea, or 
what makes him " bilious." And people are still fond of 
flying to the mysterious, and of looking for their "causes" 
among things they do not understand. Take, for example, 
the common notions about the weather, the influence of the 
moon, of comets, and the like; and the superstitious and 
vulgar errors concerning all manner of diseases, from which 
quacks of every kind reap their fortunes. The only differ- 
ence is that the delusions of the insane man, as I have said, 
have reference to himself alone, inasmuch as they are in- 
vented to account for a feeling of which he only is conscious. 
The proneness to account for it in this supernatural way is 
not peculiar to the insane, but is common to all, especially 
to those of uneducated or weak and unreflecting mind. Simi- 
larly, in dreams, cold feet make us imagine that we are walk- 
ing on ice ; an uneasy posture causes us to think we are in 
chains; or the general malaise of dyspepsia or a heavy supper 
calls up a succession of horrible fancies and vivid nightmares. 
We look on the brain of the dreamer as awake and acting in 
portions only ; when it is all awake the dream is at an end ; 
but in the case of some dreams which are extremely vivid, 
many moments may elapse before the whole force of the 
brain and the whole of its related parts can be so brought to 



THE FALSE BELIEFS OF THE INSANE. 159 

bear upon the subject as to convince us that it is a dream 
and not a reality. The brain of the insane man fails in this 
power of perceiving the whole case. 

So far we have considered those feelings of ill-being which 
express themselves in ideas of misfortune, accompanied Exalted 
by melancholy or anger ; but there are patients mani- delusions - 
festing not only in idea and delusion, but in countenance, 
manner, and action, a feeling of well being, a conviction that 
the change is all for the better, that they are stronger, 
healthier, richer, happier than ever they were in their lives ; 
and these symptoms in many cases, though not in all, are 
coincident with the presence of fatal brain disease, which 
will go on steadily and rapidly to death. All this is difficult 
to explain; nay, explain it precisely we cannot; we can only 
conjecture that the effect of this disease, which manifests 
itself in bodily paralysis as well as mental, is to blunt the 
sensibility of the brain, so that everything causes pleasure 
instead of pain to the half-roused centres : an asylum appears 
a palace, and a dinner of roast mutton a banquet of rich and 
reel her 'c7te fare. 

In all patients alike' there is the same inability to see that 
the thing is a delusion. They see it when they recover — see 
it without the demonstration which failed to convince them 
while insane. Nothing, I think, can be more certain than 
this, that during the insane state the brain cannot act as a 
whole, cannot by means of one part correct the ideas which 
arise in another. These ideas are the concomitants of 
strange and altered feelings which have a real existence ; and 
until the latter pass away, they are not to be removed by 
demonstration or argument. When the feeling subsides — 
the feeling of depression, or the excitement and elation 
which causes the grand and exalted fancies of some — the 
ideas in the majority of cases vanish also, especially if no 
long time has elapsed. The patient is said to have lost his 
delusions, and their gradual disappearance or occasional re- 



160 THE FALSE BELIEFS OF THE INSANE. 

appearance coincides markedly with the restoration of the 
general health and strength, of sleep, digestion, uterine or 
other functions. But it sometimes happens that the delu- 
sions remain after the feelings have gone, and we behold in 
the patient a confirmed monomaniac. The ideas which were 
at first the explanation to the patient of his altered sensa- 
tions are stored up as facts of experience in a damaged brain, 
which never recovers from the injury it has received, and 
never resumes its entire working power; remaining perma- 
nently unable by means of one part to correct the false no- 
tions of another, it retains forever the dream that arose in 
its half-waking period. 

The delusions most frequently met with amongst the in- 
sane may be arranged in comparatively a small number of 
classes. All, as I have said, are connected with self — the 
selfhood of the patient: all are supposed to indicate some 
change that has taken place with regard to himself. This 
change must be one for the better or the worse; a change 
affecting his worldly or his spiritual interests, his bodily con- 
dition or his surroundings ; a change which has already hap- 
pened, is happening, or is about to happen at some future 
time. The extravagance of the ideas will depend on the 
amount of brain-disorder, and we may often see this marked 
out by the delusions, as it rises to its climax, and then falls 
again to where it began. 

The delusions presented by a patient who thinks that 
things are amiss with him, may be connected, as I 
most com- have said, with his worldly or his spiritual interests. 
moniy found, -j-^ ^ extreme melancholic condition which accom- 
panies excessive depression and prostration of nerve-force, 
there will probably be delusions on both these points. The 
patient is ruined and a beggar, and he has also committed 
Delusions the unpardonable sin, and is doomed to eternal 
cha defon Zed P er dition, or he may fancy one of these things with- 
dency. ut the other. What do we learn from these de- 



THE FALSE BELIEFS OF THE INSANE. 161 

lusions? How do they affect the diagnosis and prognosis? 
We learn from them that the patient's condition is one of 
melancholia, and they ought to warn us, that in all prob- 
ability he is, or will be, suicidal. Thinking that he is 
doomed, and that life is insupportable, incapable of reflec- 
tion, and impelled by the ever-present horror of his position, 
he tries to shuffle off his mortal coil, and unless extreme 
precaution is used, he will certainly succeed. As regards 
diagnosis, the most valuable lesson taught by these delusions 
is, that the patient, being suicidal, will very likely try and 
escape, either that he may be free to commit suicide, or that 
he may wander over the face of the land to escape the evils 
that encompass him at home. The delusions may have 
reference to the past or the future ; he may be in a state of 
profound remorse for imaginary crimes, or may shrink in 
terror from tortures and torments which are to come upon 
him unjustly hereafter; but practically there is little differ- 
ence in the condition of these two varieties; frequently we 
find either kind of delusion in the same individual; either 
may impel a man to suicide, or to running away from the 
scene of his past sins or expected torments. 

As for the prognosis, it is not very unfavorable in such 
cases, provided that the bodily condition is not too 

,,,,,. . . Prognosis. 

much reduced by disease or starvation: patients re- 
cover from melancholia in large numbers, and after long 
periods of time; in fact, if they do not succumb to the disorder 
and die at an early date, we may have great hopes of restor- 
ing them to their family and the enjoyment of life. 

Some may labor under a delusion that very much is amiss 
with them ; yet their feelings may be not those of depression 
and melancholy, but rather of alarm, and restless anxiety, or 
anger and fury. So far as the delusions are con- . Delusions 
cerned, it is evident that it is optional whether we characterize <i 

' A by anger or 

call such persons melancholic or maniacal; but the fear - 
general deportment and feeling of many of them is far from 

11 



162 THE FALSE BELIEFS OF THE INSANE. 

being melancholic, and is unquestionably maniacal; while a 
certain number may be ranged with equal propriety under 
either one or the other of the two classes. 

Their delusions resemble, to some extent, those of the 
melancholic class. They imagine that some evil is going to 
happen to them. They do not, however, think they have 
deserved it, but that they are unjustly treated — that wicked 
men are conspiring to ruin them or their family, to blast 
their character, or put them to death. Here suicide will be 
rarer : more frequently we shall find attempts to escape, or 
avert by some means or other the impending catastrophe. 
Consequently you will understand that the diagnosis of such 
a patient involves the belief that he may be very dangerous 
to those about him. In order to escape he may set the house 
on fire, may try to obtain the keys from the attendants by 
force or bloodshed; may conceive the notion that those around 
him, especially strangers, are about to do him some evil, and 
murder them in supposed self-defence. A vast number of the 
homicides perpetrated by lunatics are done in fear and panic, 
especially those committed by patients suddenly waking out 
of sleep. Murders are committed by those who imagine that 
their victim has accused them of foul and unnatural crimes, 
and who suffer from hallucinations in which they actually 
hear a voice repeating these slanderous words. Or a man 
imagines that his food is poisoned, his clothes poisoned, the 
furniture and room tainted or filthy ; he will say that his food 
contains blood or human flesh : and all these fancies make 
him refuse to eat, and very violent and dangerous without 
being melancholic. 

The prognosis in such cases is not to be determined by the 
delusions alone, but must depend on the time they 

Prognosis. . . -i • - 

have existed, and on other circumstances which cannot 
be discussed here. Generally speaking, however, where such 
delusions as the foregoing have existed for a twelvemonth, 
and all the symptoms of acute disorder have subsided, the 



THE FALSE BELIEFS OF THE INSANE. 163 

prognosis is bad, and the patient is likely to remain through 
life a dangerous homicidal lunatic. 

A number of delusions are presented by those who fancy 
that the change they feel within them is all for the Delusions 
better. In their bodily or spiritual state, or worldly characterized 

** J- «/ by exaltation 

position and fortune, they are much better off than and gayety. 
before. All these are said roughly to be suffering from mania 
with elation ; but among them are included those afflicted 
with the most fatal of all the forms of insanity, — general 
paralysis. When a man between thirty and fifty-five years 
of age is full of delusions that he is of great strength, rank, 
and wealth, we may suspect that his malady is general 
paralysis, and test him by the rules I shall lay down in a 
future lecture. But frequently the same delusions appear in 
men and women who are not paralytic. They think they 
have, or are going to make, a great increase of income, that 
they are going into Parliament, are about to rise to the highest 
place in their profession, whatever that may be. All their 
speculations, however, venturesome or absurd, are to turn 
out very profitable, or they have invented, and are about to 
patent, new contrivances, which will be sources of endless 
wealth. 

If the diagnosis in such cases leads us to conclude that the 
patient is suffering from general paralysis, the prog- 
nosis is summed up in one word, — the end is death ; 
but we must not conclude too hastily from such delusions 
that paralysis is present : if it be not, patients often recover 
from this elated mania, always provided that the duration of 
the case is not so great as to make recovery hopeless. In 
fact, when there is no paralysis, no hallucination, and when 
the attack is recent, the prognosis is favorable. Neither are 
they suicidal or dangerous ; suicidal they never are except by 
accident; they have too good an opinion of themselves and 
their position. They may be dangerous when thwarted, but 
it will be merely to escape from those who wish to confine 



164 THE FALSE BELIEFS OF THE INSANE. 

them and curb their dignities and projects. They do more 
harm to property than to their own lives or those of others, 
and in their elated condition will squander a fortune in a few 
days or involve themselves in endless liabilities. And where 
recovery does not take place they often spend their existence 
very happily under a restraint which does not check their 
fancies, while it provides for their safety. 

I now come to the subject of hallucinations which are met 
Haiiucina- with daily amongst the insane, but, unlike delu- 
tions. sions, are found also in people who it must be con- 

ceded are sane. Difficult as it is to try to explain with any- 
thing like exactness the origin of delusions, it is still more 
difficult to account for hallucinations. We derive some as- 
sistance, however, from the sane and insane persons who 
can give an account of the rise and nature of these false 
perceptions of the senses; and I may say, I believe, without 
fear of contradiction, that although hallucinations 

Do haiiucina- . 

tions denote do not oi themselves prove a patient to be insane, 
yet they accompany and indicate a disordered con- 
dition of brain. They come and go as the brain health and 
force fail or improve, and point to a defective state of brain 
circulation and organization no less than delusions. The 
difference is, that being mere perceptions — auditory and 
visual sensations — they are not necessarily compounded into 
judgments, and may exist and be recognized as hallucinations 
by the rest of the brain; whereas a delusion implies a judg- 
ment formed out of more than one perception or sensation — 
a proposition which necessarily consists of more than one 
term, the falsity of which the remaining portion of the brain 
is not able to understand. In other words, an hallucination 
implies a certain disturbance of brain causing the false sen- 
sation : if the hallucination is acted upon, if something is 
doue because of it, a proposition or judgment is implied, and 
the patient may then be said to act because of the unsound 
condition of his brain and mind. 



THE FALSE BELIEFS OF THE INSANE. 165 

Hallucinations are closely allied to, nay, are, the same 
thing as frightful visions and nightmares which occur in 
children and adults, but do not come in perfect health, and 
point to some disturbance which ought to arrest the atten- 
tion of a medical man. Writers on children's diseases have 
specially noticed these night-terrors, and all who have seen 
them will agree that a child thus affected is out of health. 
They often are witnessed in children when ill of acute dis- 
orders; in fact, hallucinations constitute the chief phenomena 
of the delirium of the young. 

Whether the origin of an hallucination is primarily in the 
stomach, the periphery, or the organs of sense themselves, 
is immaterial. It is the idea-portion of the cerebrum that 
really is disordered, and that must be righted to dispel the 
false perception. The patient may be blind or saatofMu- 
deaf, but the hallucination of sight or hearing may cinations - 
be equally vivid and equally persistent. Hallucinations are 
in many cases so closely allied to delusions, and follow so 
nearly the general feeling of the patient — the melancholic 
and maniacal man hearing words which correspond to his 
gloomy thoughts, the elated having his own peculiar visions 
and voices — that it is difficult to say what is delusion and 
what hallucination ; but in the case of sane and insane people, 
the sight or sound does not always appear to have any ascer- 
tainable origin or connections, any more than certain of our 
dreams. A lady of my acquaintance, when out of health, 
always saw a cat sitting on a particular stair. She was not 
averse to cats, nor afraid of the spectral cat, but it was to her 
an index of the state of her health; tonics and wine removed 
it, to return when next she fell to a weak state. We think to 
so great an extent, by means of sights and sounds, we picture 
so much in our thoughts and hear so much, it is no wonder 
that in a disturbed condition of brain our picturing and self- 
hearing go awry. That we can see when we shut our eyes, 



166 THE FALSE BELIEFS OF THE INSANE. 

or hum an air in our heads without the least sound or 
motion of the larynx, we all know. 

Possibly hallucinations may be explained somewhat as fol- 
lows : We know that external sounds and sights 
ofhaiiucma- come to us from without through the medium of an 
external ear or eye : that they are perceived by an 
internal organ of hearing or sight, and are then transmitted 
to the higher brain- centres, and laid up in memory as ideas, 
reproducible in consciousness without the agency of the or- 
gans. Thus, a person who is blind, either from disease of 
the external organ or the internal sensory ganglia, may yet 
see with the mind's eye, and reproduce in memory the 
appearances of objects which he has stored away. Now, we 
may suppose that in the case of an hallucination the internal 
organ is excited, not from without, as ordinarily happens, 
but downwards from the idea-portion of the brain. Accus- 
tomed, however, as he is, to connect all the sensations expe- 
rienced with the external organ and the external world, the 
patient fails to perceive, sometimes at any rate, that the ex- 
citation is from within, and is firmly impressed with a belief 
that the sight which his organ of seeing really sees, and the 
voice he really hears, come from without, and not from within. 
The idea strikes his sensory ganglion so forcibly, that the 
shadow becomes a reality, which perchance may not be re- 
movable by demonstration or argument. 

We may say a good deal about hallucinations with refer- 
ence to diagnosis and prognosis, but it will be well to examine 
the hallucinations of the various senses. 

The hallucinations which arise in the state of greatest ex- 
Haiiucma- haustion are those of sight; consequently, in acute 
tions of sight. caseg f insanity, as in acute disorders of the sane, 
we find these more frequently than any other kind. They 
arise and vanish with the acute stage ; in chronic cases we 
find them less often than hallucinations of hearing. 

Hallucinations of sight may be simply flashes of light, 



THE FALSE BELIEFS OF THE INSANE. 167 

shadows, colors, or fires, or they may be objects ; sometimes 
they commence as the former, and merge by degrees into the 
latter. You are familiar with the hallucinations found in 
that disease of exhaustion which we term delirium tremens. 
In it by far the larger number are hallucinations of sight, 
visions of birds, animals, or snakes, in the room or on the bed. 
So, in fevers and other acute diseases, the wanderings and 
fears of the patient relate to what he sees rather than to what 
he hears, till at last he picks the imaginary flies from off the 
bedclothes in that stage which only precedes by a little the 
time when sight altogether fails, and he declares the room to 
be dark, though the sun is shining, or candles are burning 
in it. 

Hallucinations of sight amongst the insane are frequently 
visions of the supernatural, especially in non-acute cases ; 
patients see angels or visions of the Deity in some form or 
other, or spirits floating in the air in the shape of birds ; they 
may see the forms of departed friends or heroes, or of the 
absent; they may also see fiends, spectres, or the devil. But, 
on examination of my notes of a great many cases, I find that 
the hallucinations of sight which most strictly deserved the 
name were observed far more frequently in acute than in 
chronic cases — in cases where there was at the time great 
cerebral disturbance with violent emotional display, heat of 
head, and want of sleep. Epilepsy in the insane is con- 
stantly followed by hallucinations both of sight and of the 
other senses. 

Certain phenomena, termed by some hallucinations, ought 
rather to be looked upon as delusions: conspicuous among 
these are the mistakes of identity so common amongst the 
insane. A patient declares a stranger to be a relation or 
friend, or declares a near relation is not the person but 
somebody else — says her husband is not her husband, but a 
stranger, yet, possibly, asks after all at home — says the men 
in attendance are women, or the women men, or calls the 



168 THE FALSE BELIEFS OF THE INSANE. 

medical attendant by the name of some former friend. Very 
curious are many of these assertions ; but when they are 
made by patients who are free from all acute symptoms and 
can talk calmly on most points, we must look upon them 
as delusions of idea, and not as hallucinations, or even illu- 
sions of sight. They partake of the general change of feel- 
ing existing in the individual, which is projected outwards, 
and extended to all he sees. He thinks his wife and children 
are changed, just as he thinks himself changed into a most 
miserable or a most exalted person. The mistake is in his 
idea-region, and not in his organs of sight. Griesinger says: 1 
" The seat of hallucination of sight must be the internal 
expansion of the optic nerves. Anatomical observations have 
yet to be made on this point; in dissections, the thai am al 
surfaces, the corpora quadrigemina and their neighborhood, 
also the centrum ovale, should be carefully examined." It 
is to be feared, however, that these phenomena are due fre- 
quently to disturbances of the entire brain-function of a very 
general kind, which are not likely to be traceable after death. 
In acute diseases, no one, so far as I am aware, has ever 
thought of looking, after death, for changes which would 
account for the particular phenomena of the delirium or hal- 
lucinations. 

As hallucinations of sight occur in the acute rather than 
in the chronic stages of insanity, they do not war- 
rant an unfavorable prognosis, inasmuch as there 
is more hope of recovery during the acute than during the 
chronic period. The prognosis of the case will depend, not 
upon these, but upon other symptoms, and the diagnosis will, 
by the same rule, be attended with no difficulty. In chronic 
cases I have generally found that where hallucinations of 
sight existed, others, especially of hearing, existed also. Of 
all the hallucinations caused by such substances as haschisch, 
opium, and the like, those of sight are the majority. 

1 Sydenham Soc. Trans., p. 98. 



THE FALSE BELIEFS OF THE INSANE. 169 

Hallucinations of sight often occur in the dark, in which 
patients see not merely flashes of light, such as might be 
attributed to irritation of the optic apparatus, but actual ob- 
jects — men or animals. This proves that the idea-region of 
the brain is the seat of the mischief, which is corroborated 
by the fact that blind persons are subject to hallucinations as 
well as those who can see. Curiously enough, many patients 
can dispel these hallucinations by closing the eyelids or cover- 
ing the eyes. This is easily explained by the association of 
ideas. Being habitually unable to see anything with the 
eyelids closed, they do not see these phantoms of their dis- 
eased imagination. 

In non-acute insanity, hallucinations of hearing are the 
most common and the most formidable. They are 

. Hallucina- 

dimcult to eradicate, and while they exist they tionsofhear- 
render him who hears them the most dangerous l 
of patients. In chronic cases, or in those in which insanity 
has revealed itself gradually and insidiously with few acute 
symptoms, hallucinations of hearing form at least two-thirds 
of all that we meet with. And when a patient of this class 
tells us that he or she hears "voices," not mere sounds, 
whistlings, humming, or the like, but words and sentences, 
we augur unfavorably of the case; our prognosis is gloomy, 
and our diagnosis is that such a one requires close watching 
and restraint. I have known patients lose the fancy of mere 
sounds. One gentleman used to hear "blowpipes" whistling 
down his chimney, and whistling at him in the street, and 
these by degrees vanished, but his mental health was never 
fully restored. He leads in solitude the life of a hypochon- 
driac, and when he is a little more nervous than usual, he 
hears singing in his ears, and shows incipient symptoms of 
his former hallucinations. Patients hear voices either of those 
they know, or of unknown persons, natural or supernatural. 
As no one is to be seen, they generally imagine that the 
speaker is in the next room or house, or in a cupboard or 



170 THE FALSE BELIEFS OF THE INSANE. 

chimney. Of course, if it be a supernatural voice, it may 
come from the air inside or outside the house. One lady was 
so annoyed by voices coming through the wall that she pur- 
chased the adjoining house to compel them to cease. I need 
not say she did not so get rid of them. Many patients' 
whole lives are regulated by the commands they receive from 
"the voices." They eat, drink, walk, and sleep according to 
the commands they hear, and if compelled to act contrary 
to them, they tell us that they will suffer for such disobedi- 
ence. They obey implicitly, holding the voice responsible, 
and so will commit frightful crimes without looking upon 
themselves as guilty or responsible. And as many patients 
will not reveal what the voices say, it follows that the whole 
class is eminently dangerous and uncertain. It often hap- 
pens that there is great difficulty in extracting from a patient 
the confession that he hears voices, or that which the voices 
say. He appears afraid to tell, and seems bound down by 
some kind of compact not to do so. He thinks it a point of 
honor to conceal what passes, and it is only by our overhear- 
ing him answering in imaginary conversation that we ascer- 
tain the fact. 

We may sometimes detect hallucinations of hearing in pa- 
tients who have never revealed them, by noticing while we 
talk to them that they from time to time are inattentive, and 
appear to be listening to some one else. On being pressed, 
they will probably confess that they hear some one speaking. 
There is often the closest connection between the delusions 
of a patient and that which he hears. The latter is, in fact, 
the delusion done into audible words. Thus, a patient who 
hears a voice accusing him of various crimes, unnatural lust, 
and the like, entertains these delusions at all times. But 
there is great variety in what the voices say, and sometimes 
it appears to have no connection with other well-known de- 
lusions to which the individual is subject. 

In some patients these hallucinations seem to deserve the 



THE FA.LSE BELIEFS OF TIIE INSANE. 171 

name of illusions, for though they take the form of voices 
and intelligible words, they are not heard in perfect stillness, 
but only when there is a noise going on ; which noise, what- 
ever it may be — footsteps, the rattling of a door or window, 
or the wind — is converted into "voices." On the other hand, 
it is often difficult to distinguish between such hallucinations 
and mere delusions, to say whether the patient imagines that 
he is falsely slandered and accused, or hears voices repeating 
the words. And yet our prognosis may be materially affected 
by the one or other of these symptoms. 

We know very little of the pathology of hallucinations of 
hearing. Empirically, we find that they are most 

t /v i p i -ii • rc nil Prognosis. 

dimcult of removal, and that patients anected by them 
are amongst the most incurable of all lunatics; but we have 
no knowledge of the pathological lesion which enables us to 
account for this. Neither can we say why they predominate 
in the non-acute forms of insanity, whilst in the acute hal- 
lucinations of sight are far more common. These are ques- 
tions still open to examination. 

Hallucinations of smell belong to the acute states of in- 
sanity rather than to the chronic ; and when the pa- H aiiucina- 
tients get better, they vanish. Some will tell us tiullsofsmdl - 
that they smell fetid and noisome exhalations, the scent of 
the dead, or of vaults and catacombs, or say that their food 
or drink smells offensively, and for this reason refuse it. 
More frequently, however, they assert that an offensive odor 
proceeds from their own bodies, rendering them horrible to 
all about them, and contaminating the chairs, sofas, or beds 
they rest upon. This was the case with a gentleman, the 
subject of melancholia, who would only sit on a caned chair, 
because he thought that he polluted a stuffed one. A young 
lady always presented me with her smelling-bottle, because 
of the odor she believed to exhale from her, which must be 
disagreeable to me as I stood and talked to her. Both these 



172 THE FALSE BELIEFS OF THE INSANE. 

patients recovered from somewhat acute attacks of melan- 
cholia. 

Hallucinations of taste are so interwoven with disordered 
Haiiueina- sensations, depending on the state of the tongue or 
uons of taste, alimentary canal, and with delusions concerning the 
food, that it is difficult to lay down anything with precision 
on this head. The patients who say that baby's flesh, human 
blood, human excrement, arsenic, or other poison, is put in 
their food, do not fancy they taste these substances. The 
idea is a delusion, not an hallucination. From my own ex- 
perience, I am inclined to believe that true hallucinations of 
taste are uncommon, that they rarely exist alone, and that, 
depending on a disordered state of digestion, they generally 
are transient. 

A number of curious phenomena may be grouped under 
other haiiu- the title of hallucinations of the skin and muscles. 
cmations. It is not uncommon to find a patient who calmly 
tells us that he feels himself touched on various parts of his 
body by little raps or shocks. A young gentleman felt these 
long after every other symptom of insanity had disappeared. 
They latterly gave him little concern, though at first he attrib- 
uted them to supernatural causes. He had no other hallu- 
cinations. Others feel electric shocks, but these are often the 
subjects of delusions rather than of hallucinations. Some feel 
snakes in their inside. One lady had a dog in her head, and 
complained of the sensations it caused. This I look upon 
rather as a delusion. Some patients declare that they have 
felt persons have sexual connection with them. These are 
onanists, or patients with morbid sexual desires. Others 
constantly declare themselves to be with child, and say they 
feel it moving, or labor approaching. These are all delusions. 
Disordered muscular sensations, the feeling of being bound 
and incapable of moving, may be akin to that experienced in 
nightmare, when w r e are pursued by a lion and cannot run 
away, or are falling from a precipice. 



THE FALSE BELIEFS OF THE INSANE. 173 

Patients may experience hallucinations sometimes or 
always. One gentleman told me he could always hear the 
voices if he listened for them. Some only hear voices when 
there is a noise of some kind in or out of the room. In all 
who are subject to hallucinations, we find them most frequent 
and most distressing when the bodily strength is lowest. 
They point to an exhausted nervous state, even more than 
do delusions, especially the hallucinations of sight, which 
generally exist in acute diseases of exhaustion, as fever and 
delirium tremens, or can be produced by such poisons as 
haschisch, stramonium, or belladonna. 



LECTURE VIII. 

The Acts of the Insane — Stripping Naked — Indecent Exposure — Fan- 
tastic Dress — Eating and Drinking — Habitual Drunkenness — Suicide 
— Self-mutilation — Talking to Self — Squandering Property — Homi- 
cide, for various Reasons — Pyromania — Erotomania — Kleptomania. 

By the discovery of false beliefs or delusions, we are led 
to the conclusion that patients are insane. Let us now con- 
sider insane acts ; for by these, no less than by delusions, we 
may be guided to the same opinion. As we find insane per- 
sons who have no delusions, so we see others whose unsound- 
ness of mind is not displayed in acts, or, at any rate, in such 
of them as are observable by us ; for we should learn a great 
deal more of many patients if we could watch them without 
their knowledge. Without discussing in this place the diag- 
nosis of insanity, and its recognition in those who commit 
insane acts without delusions, or have delusions without dis- 
playing anything insane in act or conduct, I wish to review 
the chief acts which arise from the insanity, and are the best 
evidence of it. As insane beliefs range themselves under 
certain heads, so we shall find that similar acts are perpe- 
trated by many insane people, emanating without doubt from 
a corresponding mental condition. As the discovery of certain 
delusions leads us to inquire whether the individual has done, 
or attempted to do, certain things, so the acts help us to dis- 
cover the delusions. Many acts which, taken by themselves, 
would not prove insanity, are, when explained or justified 
according to the insane ideas of the individual, valuable 
evidence of his state of mind, and often afford a clue which 
otherwise would be wanting. 



THE ACTS OF THE INSANE. 175 

We may roughly class insane acts under two heads, — those 
which affect the person or property of the patient, Two classes 
and those which affect the person or property of of acts - 
others. Under the first head, we shall consider such acts as 
stripping off all clothes, indecent exposure, fantastic L Those 
dress, self-mutilation, starvation, suicide, dipso- ^thepa^ 
mania, squandering of property ; while under the tient. 
second we find homicide, arson, rape, and acts of violence or 
mischief of innumerable kinds. Every one of these may 
become a subject of investigation in a court of law, and it is 
as well to examine them by themselves, just as we examine 
and consider delusions and hallucinations. 

Stripping stark naked is not unfrequent amongst the in- 
sane. And in this condition they will run out of stripping 
their room, or the house, regardless of decency. Put- off clothos - 
ting aside all the cases where patients have got rid of their 
clothes in a struggle, we shall find that they strip themselves 
either from a desire to destroy everything within reach, or 
from a wish to get rid of the feeling of heat or restraint 
engendered by clothing. In the latter case they may re- 
move without destroying it; this they may also do thinking 
it filthy or poisoned, or may ruin it from pure mischief and 
wrong- doing. 

In acute insanity, acute delirium, acute mania, and melan- 
cholia, it is common to find patients stripping off their clothes, 
and tearing them to pieces to get them off. The feeling, 
whether of restraint or of heat of skin, is one due to the 
physical condition, and they accomplish their end without 
assigning any cause whatever. Such patients are beyond 
the reach of argument or expostulation. The symptom, like 
the disorder, is of a temporary nature, and must be met with 
measures best suited to the case, by fastening blankets round 
the patient, or by placing on him a suit of strong material 
laced up the back, which he can neither tear nor remove. 
It is essential that many of these persons should be kept 



176 THE ACTS OF THE INSANE. 

warm, as also those affected with general paralysis, who are 
given to stripping themselves if left alone at night. 

Chronic maniacs who are noisy, mischievous, and destruc- 
tive, but perfectly conscious, destroy their clothes from pure 
wantonness, just as they smash furniture and windows, or 
befoul their beds and rooms. Blankets or strong suits are 
of little use for them, as they are quick and ingenious 
enough to pick these to pieces by dint of nails and teeth, 
and, if left alone, each morning discloses a scene of rags and 
pieces, the result of a diligent night's work. These patients 
are good illustrations of the nonsense talked about the knowl- 
edge of right and wrong being a test of sanity. They know 
as well as any one that what they do is wrong, and they de- 
light in doing it, because it is wrong. I have never found 
any expedient of use but the presence of an attendant, or 
two, if necessary. When the patient finds that he is not 
allowed to destroy, he gives up, and in time loses the habit 
and desire. 

In a case where the clothes are stripped off or destroyed 
in conformity with certain delusions, such delusions will 
commonly be assigned as the reason. These must be met 
like any others, and will pass away as the patient improves. 
They generally belong to an acute stage, and are found in 
connection with hallucinations of smell, or sensations of the 
cutaneous surface. 

As a matter of diagnosis little need be said in connection 
with this subject; the insanity of such patients will be patent 
in many other ways ; at the same time, sane people do not 
strip themselves naked except for justifiable reasons, and 
such stripping may be adduced as evidence of insanity along 
with the other symptoms which are sure to be observable. 

The same cannot be said of the next topic I shall mention, 
indecent indecent exposure of the person. This is constantly 
exposure. practiced by sane people, as the records of our crim- 
inal courts prove. It is done by the insane both in the acute 



THE ACTS OF THE INSANE. 177 

and chronic state. It is a not unfrequent symptom in the 
early stages of general paralysis; it is often done by patients, 
men and women, who are passing from the stage of chronic 
mania to that most hopeless condition, chronic dementia. 

We are not to infer insanity from such an act unless there 

t/ 

be other corroborating symptoms ; but when these leave no 
doubt in our minds that the patient is insane, our prognosis 
of the case, whether it be acute or chronic, will be unfavor- 
able. I am speaking, of course, of a deliberate act of inde- 
cent exposure, not of the accidental exposure which occurs 
when an excited patient strips himself or herself entirely. 

Open and shameless masturbation is a common occurrence 
in patients both in the acute and chronic state. 

We shall constantly see something bizarre or extravagant 
in a patient's dress and general appearance, which, Failtast ic 
if it does not of itself prove insanity, may at any dress - 
rate reveal the delusions which prompted it The hair, the 
condition of face and hands, the clothes, articles attached to 
the dress as ornaments, the state of the nether garments, 
shoes, and stockings, may all betray singularity, and corre- 
sponding singularity of ideas. One might fill a volume with 
anecdotes of the extraordinary appearances presented by 
patients under the influence of delusions. There are few 
who dress just as they ought, if they have the opportunity of 
giving the rein to their fancy. The man of exalted ideas 
wears a crown or coronet of paper or straw ; orders and bits 
of ribbon adorn his button-hole ; he winds shawls, rugs, or 
sofa-covers round him for robes. The melancholy man thinks 
it is not worth while to wash his face or body, or brush his 
hair ; unwashed and unkempt, in ragged or untidy clothes, 
he mourns his destiny. The apartment in which a patient 
habitually dwells frequently presents appearances which cor- 
respond to his personal dress and demeanor, and may vary 
from the height of eccentric tidiness to the extreme of filth. 
Constantly, if it be one which the patient has tenanted for 

12 



178 THE ACTS OF THE INSANE. 

some time, we shall find signs of singularity of conduct and 
idea. Many choose to keep all their provisions and do all 
their own cooking in their living-room, from fear of poison ; 
others sleep in strange fashion ; others keep numberless ani- 
mals. In every case where we notice oddity of appearance 
in an individual or his surroundings, we are to bear the facts 
in mind, and question the patient as to their meaning; but 
we are not in every case to infer insanity, for eccentricity 
may exist to a great extent without insanity, and is often 
displayed in outward adornments. If, however, we are called 
to a person who has never been eccentric in demeanor or 
dress, and who suddenly decks himself in strange and un- 
wonted garb, we may do more than suspect insanity. 

The degree of dirt compatible with sanity is a question 
which will vary according to the experience of the observer. 
Those who are familiar with the beggars of the south of 
Spain or Italy, will think this test very uncertain ; but here, 
too, the same rule is applicable. If an educated and hitherto 
respectable gentleman appears in a state of deplorable filth, 
we may well question his sanity. 

Our prognosis will not be much influenced by such appear- 
ances, but further information will be required. If the case 
is recent, the oddity of the appearance is of little moment; 
if chronic, some very slight token may point to a delusion 
which may have existed for years, and is not likely to be 
removed. 

A patient's eating and drinking may arrest our attention. 
Eating and He may eat voraciously, or very little, or absolutely 
drinking. no thing. He may eat only such things as eggs, from 
fear of poison ; or only the food cooked by himself; or he 
may require others to taste everything before he partakes of 
it. He may eat filth of all kinds : in fact, there is nothing 
too nasty to be carried to the mouth by the insane in all 
stages of the disease. Such acts are evidence of unsound- 
ness of mind, generally of dementia or idiocy. Absolute 



THE ACTS OF THE INSANE. 179 

abstinence from food would also warrant our coming to the 
conclusion that the individual was unable to take care of 
himself. Between these extremes, singularities of diet and 
mode of eating, like eccentric personal appearance, point 
our way to the detection of insanity, but are frequently not 
in themselves and by themselves evidence thereof. Cases 
are on record where patients have swallowed such articles 
as lancets or a pair of compasses, and have habitually 
eaten nails, coals, rags, tobacco-pipes, &c. ; but we know, 
from the post-mortem examinations of our general hospi- 
tals, that these depraved and perverted tastes are not pe- 
culiar to the insane, but are indulged in similar ways by 
sane persons. The eating of hair by girls, and the chewing 
of slate-pencil, are by no means uncommon — and I have 
heard young ladies descant on the pleasures of the latter. 

It may be as well to mention in this place that craving 
for alcoholic drink, which has been called by some Habitual 
a monomania, under such titles as dipsomania, oino- drunkenness - 
mania, methyskomania, and by others is merged in the class 
of moral insanity. Perhaps for the practitioner and the 
medico-jurist, this is the most perplexing of all varieties of 
unsoundness of mind, if — and this is a moot point — it is of 
itself unsoundness of mind. I have already, in my third 
lecture, said something concerning the pathology of alcohol- 
ism. I have here to inquire whether drinking to the extent 
of what is called dipsomania, is an insane act. There can 
be no question that there are hundreds of habitual drunkards 
who are in no sense insane. The very fact that a certain 
proportion of them abandon the habit, reform, and for the 
rest of their lives live temperately, shows that they are not 
suffering from chronic insanity. To them inebriate asylums 
are a boon, not because they are insane, but because they 
require assistance to enable them to break through a bad 
habit, like an inveterate smoker, snuff-taker, opium-eater, 
gambler, or masturbator. There is, again, a number of in- 
sane people who drink, whose insanity is shown not merely 



180 THE ACTS OF THE INSANE. 

by their drinking, but by their whole history and acts, or by 
the presence of other neuroses, as epilepsy. And there are 
patients who, by long-continued drinking, have brought 
about disease of brain ; but habitual drinking, by itself, is 
not to be considered evidence of insanity, if the drinker, 
when sober, presents no other indication. Dipsomania is no 
more a special variety or monomania, than pyromania, eroto- 
mania, or kleptomania. 

We may notice in the next place the acts of self-mutila- 
tion and self-destruction so often committed by the 

Suicidal acts. . 

insane. It we walk round the wards even of a 
small asylum, we shall rarely fail to find some one or more 
patients who have tried, with more or less success, to do 
damage to themselves. They may be laboring under suicidal 
melancholia, or other forms, as that which is called suicidal 
monomania or suicidal impulse. Critics and writers on the 
subject vary greatly in opinion, some thinking that all who 
commit suicide are insane, others that delusion must be 
ascertained before we can pronounce any suicidal or homi- 
cidal patient to be of unsound mind. I have coupled sui- 
cidal and homicidal patients, for the condition of the one is 
often closely allied, or even identical, with that of the other 
class. The same patient often commits both homicide and 
suicide, or at one time is homicidal, at another suicidal ; and 
so, in reducing to a number of heads the patients who are 
homicidal, we find that we can range in almost identically 
the same divisions those who are suicidal. It is of the latter 
that I shall first speak. 

That sane people commit suicide is a fact that must be 
apparent to every one who exercises common sense in look- 
ing upon the subject. The hundreds of poor creatures who 
are rescued from the Thames, or brought to our general 
hospitals half poisoned, or with throats half cut, are not in- 
sane in any medical sense of the word. Putting these aside, 
let us look at the insane who are suicidal. 



THE ACTS OF THE INSANE. 181 

I. First, we have the melancholic patient, who has been 
noticed by his friends to be a little low-spirited but nothing 
more. They have not heard of any delusions; he has not 
done or said anything that could warrant their calling him 
insane. He has only appeared changed in spirits and capacity 
of enjoying himself, and this they have thought it better not 
to notice; so he blows his brains out, or jumps from the top 
of the house, and then they are extremely anxious that he 
should be called insane, and not felo de se. This is pure 
suicidal melancholia, insane iced turn vitce, where, without any 
marked or overwhelming delusions, the whole feeling of the 
individual makes him look on life as not worth the keeping. 
He is perplexed and annoyed with everything and every- 
body : 

" Weary, stale, flat, and unprofitable, 
Seem to him all the uses of this world." 

And so he ends them. We see the insanity of the man 
in that he is entirely changed from what he was ; there is 
no cause for his melancholy, but perhaps there is cause for 
his insanity, his suicidal melancholia. 

II. The malady may still be fitly called suicidal melan- 
cholia; but the desire to commit suicide may be directly 
prompted by delusions, e. g., that he is going to be horribly 
tortured ; or he hears a voice commanding him to kill him- 
self; or he thinks that by this he shall gain heaven ; or he 
is ruined, and shame and poverty are staring him in the face; 
or he sees visions of the departed beckoning him to come to 
them. This form is easy of diagnosis, and the prognosis is 
favorable if the general health be not much broken. Of this 
I shall have to speak when I come to the subject of melan- 
cholia. 

III. In almost any case of acute insanity — in delirium 
tremens, in epileptic mania — suicide may be committed in 
fear, in a paroxysm of rage, or in a general outburst of de- 
structiveness ; or in attempting to escape a man may jump 



lbZ THE ACTS OF THE INSANE. 

from housetop or window without any definite idea of self- 
destruction. In all cases of acute insanity, acute delirium, 
acute mania, and the like, this must be borne in mind, and 
opportunities of self-harm removed from a patient. Many 
at this time are subject to paroxysms of ungovernable fury, 
and will then try and hurt themselves as well as others ; they 
will dash their heads against a wall, bite their arms, or even 
do more serious mischief if they have the chance. We can- 
not say that they are suffering from suicidal melancholia or 
suicidal mania. Suicide is like breaking the windows, or 
tearing in pieces their clothes or furniture — a mode in which 
their vehement destructiveness finds vent. Of the insanity 
of such persons there is, of course, no doubt, and the progno- 
sis is not affected by the fact that suicide has been attempted. 
IV. Besides these, we find true suicidal mania and suicidal 
impulse. Patients both in an acute and unmistakable state 
of insanity, and in one that is hardly recognizable as being 
insanity except in this one feature, have a violent desire and 
longing to commit suicide. According to their capacity of 
self-control, they may make the attempt all day long, so as 
to require an attendant to be constantly within reach ; or may 
keep it to themselves for days, weeks, or months, till they 
see a fitting opportunity of satisfying the desire. Although 
in a state of marked insanity, their delusions may have no 
connection with suicide, and their feelings and demeanor 
may be the reverse of melancholic. The most suicidal pa- 
tient I ever saw was a friend who was perfectly free from 
everything like low spirits, and whose delusions, of which to 
me he made no secret, had no reference whatever to any of 
those things which usually prompt patients to suicide. One 
might have conversed for hours with this gentleman, and 
given an opinion that he was a patient not likely to be suici- 
dal, yet he would do himself harm in every way he could — 
swallow scalding beef-tea, try to strangle himself over a five- 
barred gate ; in short, in some way or other hurt himself. 



THE ACTS OF THE INSANE. 183 

He went on in this way for some two years, the suicidal im- 
pulses occurring in paroxysms every two or three months, 
and then died epileptic. 

Suicidal impulse occurs in children, who, when they com- 
mit this act, do so usually not from delusions or from settled 
melancholy, but from pure motiveless impulse. There is an 
uncontrollable desire to gratify the morbid idea which is 
present in the mind, as in dipsomania there is the desire to 
gratify the physical craving of drink, regardless of all conse- 
quences. Just as in the case of a patient suffering from some 
foolish and absurd delusion, the rest of the brain is not suffi- 
ciently at work to correct the falsity thereof; so here it is 
not sufficiently at work to correct, by ideas of duty, prudence, 
and self-love, the feeling and idea which urge to self-destruc- 
tion. Probably, in many cases both of murder and suicide, 
the insane man or woman experiences in an insane degree a 
feeling of anticipated pleasure or curiosity akin to that felt 
by the spectators of the horrors of the amphitheatre or auto- 
da-fe of past times, and of the bull-fights of our own days — 
a morbid delight, nay, a keen enjoyment of a ghastly spec- 
tacle. 

Besides those who try in every way to put an end to them- 
selves — who will refuse food for this purpose, and seir-mutna- 
lose no opportunity of doing to themselves bodily tiu " 
harm, however trivial — there are patients who, for definite 
reasons, will damage or mutilate some one or other part of 
their bodies. Some, following the literal precept, will pluck 
out their eye or cut off their hand. I have a lady under my 
care now whose right eye was destroyed under these circum- 
stances. Frequently the organs of generation — the penis, or 
the testicles, or the whole — are cut off, because they are sup- 
posed to have " offended," to have incited the patient to 
wicked lusts, or to have been the means of gratifying them 
through masturbation. Patients will set themselves on fire, 
place their hands in the candle or the coals, to inflict upon 



184 THE ACTS OF THE INSANE. 

them the torments of hell, and will display a fortitude or an 
indifference to pain in so doing that is truly marvellous. All 
such acts are done from delusion, not from mere impulse, as 
the acts of suicide. Whether it be from one or other motive, 
such patients demand constant and unceasing vigilance on 
the part of those about them. They are safe nowhere save 
in an asylum, and even there they are the source of end- 
less anxiety. Being for the most part in full possession of 
their faculties, they never let an opportunity escape of secret- 
ing a knife, a nail, a piece of broken glass, or a bit of cord. 
They will do themselves a mischief under the bedclothes with 
an attendant sitting by their side, and not indicate it by a 
muscle of their countenance; and when all weapons are taken 
away, they will gouge out their eye, or pull down the rectum 
with their fingers. 

Besides desperate injuries inflicted on themselves by 
patients, either through strong delusion or expressly from 
suicidal motive, many daily do themselves smaller mischiefs 
without any motive at all. This one picks his face or hands 
till he covers them with sore places, from restless fidgetiness; 
another bites his nails down to the quick ; another plucks 
out hair after hair from his head till he is nearly bald. Such 
tricks, less perhaps in magnitude, are common among nerv- 
ous people who are not insane. Most nervous persons have 
some trick or twitching, and, like the insane, twist and fidget 
their dress, or pick and scratch their hands, face, head, or 
limbs: the extent to which they do it at any given time is 
often a valuable criterion of their nervous condition. 

There is another common habit of the insane which must 
be noticed, that is, talking to themselves. Many people who 
Talking to are sane talk to themselves: they automatically con- 
seif. vert j n ^ auc ii D i e WO rds those the} 7 are combining 

in thought, so that this talking to self is not to be reckoned 
as a sign of insanity. But it is often done by the insane 
in a way and in a tone that is strongly symptomatic of 



THE ACTS OF THE INSANE. 185 

the disorder; and frequently, if we listen, we find that 
they are holding conversations with imaginary beings, and 
answering imaginary voices. And by so listening valuable 
information m&y be gained as to what is passing in the pa- 
tient's mind — information which he will not give us when 
questioned. 

Hitherto I have spoken of what is done by a patient, so far 
as it relates to his own person. But he may also squandering 
squander, destroy, or give away his property, and P ro P ert y- 
measures will be necessary to protect this no less than him- 
self. But the man who squanders or destroys his property 
is not the same as he who harms himself. The latter is com- 
monly a melancholic, who thinks he has no property, or, in 
the overwhelming fear and anxiety that possesses him, ne- 
glects it entirely. The man who squanders it is he who in 
his exalted notions thinks himself a millionaire; or, imagin- 
ing; he can find a source of endless wealth, beggars himself 
to discover his El Dorado, or who makes presents to every 
one he meets, and orders silk dresses or jewelry to be sent to 
all he knows. In every asylum we see such patients. They 
spend their days in writing letters to every shop whose ad- 
vertisements they see in the Times, and ordering goods to the 
extent of hundreds or thousands of pounds. And before they 
are put under legal control such orders are often given, and 
great trouble is experienced in getting them annulled. Then 
there is the senseless squandering of money by the imbecile 
class, who have not brains enough to know its value. We 
may see the same thing done by patients in the first stage of 
senile or other dementia. This, together with debauchery 
and indecent conduct, is often the earliest symptom of the 
decay of mind. 

I now proceed to consider insane acts committed upon the 
person or property of others. In this category we 2 ictsdone 
shall have to examine the so-called homicidal mono- towards. 

others. 

mania ; pyromania, or arson ; erotomania, or rape ; 



186 THE ACTS OF THE INSANE. 

and kleptomania, or pilfering. And first of homicide, the 
gravest question of all, as an excuse for which it has 
been said that the homicidal monomania has been 
invented. Here, as in the case of suicides, some writers and 
physicians hold that the crime may be committed from moral 
obliquity equivalent to insanity, which they term " moral 
insanity;" others say that murders are committed from sudden 
insane impulse; while many, especially lawyers, require that 
delusions shall be found before they admit that the perpe- 
trator is insane, and even then do not allow that in all cases 
the insanity is a bar to punishment. This is not the place 
for the consideration of moral or impulsive insanity. I shall 
confine myself at present to the homicidal act, as it is com- 
mitted by this or that patient, assuming that impulsive in- 
sanity has at any rate a recognized existence. 

I. Homicide may be perpetrated without any impulse or 
From a wish delusion by a patient enraged at being restrained, 
to escape. simply to free himself from detention. Many of 
the attacks to which attendants are subject are of this nature. 

II. It is frequentty done under delusions of various kinds. 
Fromdeiu- The patient thinks that he is himself about to be 
sion. tortured, murdured, or led to prison, and he slays 
the man who is his fancied enemy. He will kill his wife or 
children to save them from worse ills which he thinks are to 
befall them. He fancies that he has a Divine mission to 
murder some one, or hears a voice urging him on, or the 
voice of some one he knows insulting him — and this will 
probably be the voice he hears oftenest, his attendant's or 
doctor's. These delusions vary indefinitely ; but where the 
crime is committed from such a motive, it is generally con- 
fessed, and the insanity is manifest. It is not possible in 
every case to connect the delusions of a patient with the act 
of murder, yet we are not on that account to assume, as do 
the lawyers, that there is no connection between them. 
Whence delusions spring, and whither they lead an insane 



THE ACTS OF THE INSANE. 187 

man, is what no one can tell. To attempt to trace a mad- 
man's ideas from their source to their outcome in act is at all 
times an unprofitable task. 

III. Murder is committed by an idiot, imbecile, or de- 
mented patient, from wanton mischief, or folly, from 

. From idiotic 

ignorance of the act and its consequence, or from or wanton 
mere imitativeness. An idiot may kill a child be- mis 
cause he has seen a fowl or a sheep killed. 

In all the preceding classes the unsoundness of mind of 
the homicide is patent. There is no question of diagnosis. 
Lawyers may quibble about the responsibility, but medical 
men will detect the insanity, which is not left to be inferred 
from the homicidal act alone. 

There are also acts of homicide committed by persons 
whose soundness of mind was never called into question 
before the murder, and these may be arranged in three 
classes. 

IV. Homicide is not unfrequently committed by epileptics. 
Epilepsy is not the equivalent of insanity. Many In epileptic 
persons suffer from epileptic fits for years, yet mix furor - 

in society and discharge the duties of sane and responsible 
people. But it has been asserted, and not without good 
grounds, that the mental condition of an epileptic is not 
thoroughly sound. "All authors are agreed," says Bail- 
larger, 1 "in admitting the fact that epilepsy, before leading 
to complete insanity, produces very important modifications 
in the intellectual and moral condition of certain patients. 
These sufferers become susceptible, very irritable, and the 
slightest motives often induce them to commit acts of violence; 
all their passions acquire extreme energy." An act of mur- 
der may be committed by an epileptic in the furious mania 
with hallucinations and delusions which follows a fit or suc- 
cession of fits. It may also be done in the period which pre- 

1 Ann. Medico-Psych., Avril, 1801. 



188 THE ACTS OF THE INSANE. 

cedes a fit, a period during which, especially, some patients 
show strangeness of mind and manner. And the convulsion 
may be exploded, as it were, in the act of violence, the fit 
not occurring as it otherwise would have done. Murder may 
also be committed by patients rendered weak-minded by fits. 
In 1869, Bisgrove, an epileptic, was tried and found guilty 
of murder, but afterwards removed to the Broadmoor Asylum. 
He saw a man lying asleep in a field; he did not know him, 
but took a big stone that was lying near, dashed out his 
brains, then lay down by his victim's side and went to sleep. 
From epileptics, generally, we may expect acts of sudden and 
unaccountable violence, whether they occur in close connec- 
tion with fits or take the place of them. 

Y. Murder may be committed during a paroxysm of in- 
sanity, brief, but furious, which, from its duration, 

In acute ■/.? ? " ' " 

transitory we m ay ca li transitory mania. Here, while it lasts, 

mania. , . V . . 

the insanity will be recognizable; but as it rapidly 
passes off, and possibly has never occurred before, the diffi- 
culty will be to discover any traces of unsoundness of mind 
a few days after the event. Such attacks are really for the 
time paroxysms of acute mania. The patient afterwards 
may not be conscious of what he has done, and by his ex- 
pressions at the time may or may not indicate the feeling or 
delusion that prompts him. Frequently mania occurs in 
patients suddenly waking out of sleep, and is of the char- 
acter of a nightmare, probably a continuation of some hor- 
rible dream. The act is often committed in a state of panic 
rather than rage, and the committal may thoroughly bring 
the patient to his waking senses, and to the contemplation 
of what he has done. 

VI. Lastly, homicide, like suicide, may be committed from 
impulsive "homicidal impulse." We are told that a man is 
homicide. i m p e u e d to commit murder by a craving impulse, like 
the craving thirst for drink. It is in cases of homicide that 
this variety, impulsive or instinctive insanity, is chiefly 



THE ACTS OF THE INSANE. 189 

alleged and criticized ; and, merely mentioning here that 
homicide may be committed in this fashion, I postpone the 
discussion of this insanity to a subsequent period. 

Besides the homicidal monomania, we hear of others, as 
erotomania, kleptomania, pyromania. Having already 

.,, Tn • i i • • i l ■ ■ Pyromania. 

said that 1 do not consider homicidal monomania to 
be a specific disease, I still less acknowledge that the acts 
which these terms indicate proceed from special disorders. 
They are committed by insane patients of various kinds, but 
the insanity is not likely to be confined to one of these acts, 
but is sure to be noticeable in other ways, if it exist at all. 
To take the last mentioned, pyromania, we might as well 
erect into a special form the window-breaking mania. Pa- 
tients set fire to the house out of an insane impulse to de- 
stroy, as they break windows or anything else. They will 
do the same thing, in order to escape in the confusion. This 
has happened several times. within my knowledge. They 
may do it from suicidal motive, or from commands received 
from hallucinatory voices. But a sufficient examination of 
such patients and their history will reveal insanity other 
than the mania for incendiarism. 

Neither is erotomania a special form of insanity; there are 
numberless patients who in their mental disorder 

, , Erotomania. 

present marked erotic symptoms, lhe majority of 
young women in states of acute mania do this, and will assail 
the physician with words or embraces if he is not on his 
guard while visiting them ; but all this is a result of their 
insanity : it does not constitute it. Those who have exalted 
erotomania into a special monomania, say that it is not the 
same thing as nymphomania or satyriasis ; that the disorder 
is not in the reproductive organs, but in the head, and that 
it is an error of the understanding, an affection of the imagi- 
nation, in which amatory delusions rule. 1 If this be so, a 

1 Esquirol, Malad. Mcnt. ii, p. 32. 



190 THE ACTS OF THE INSANE. 

fortiori we may deny that it is a special variety of insanity; 
it is a form of disordered intellect, accompanied by delusions. 
I have known girls conceive an insane love, not for men, but 
for other girls, and fancy themselves influenced by them, and 
in their power ; and I presume this would come under Es- 
quirol's erotomania ; but in one case these preliminary fancies 
culminated in an attack of acute mania, and there was nothing 
about the case which removed it into any special category. 
In the acute stage, it might have been called nymphomania 
rather than erotomania. We may be justified in describing 
forms of insanity in which either the origin is in the sexual 
organs, or there is marked disturbance of the latter. Such 
a division would be in accordance with pathology ; but a class 
distinguished by intellectual disturbance, in which love is 
the chief feature, is not really separable on this account 
from other forms of insanity where there is disorder of intel- 
lect, with or without delusion. 

I now come to kleptomania, another of these forms of in- 
sanity from so-called perverted emotion or impulse. 

Kleptomania. . . 

And of this I would say, as of the foregoing, that 
it cannot be exalted into a class. Lunatics, undoubtedly, 
steal both in and out of asylums. When their lunacy is be- 
yond a question, little is thought of their stealing ; but when 
it is not so easy to detect, then the stealing is set up as proof 
of insanity, if the thief is in a social position to make us 
astonished at the act. 

When we hear of a theft committed by a person supposed 
to be insane, but not clearly proved to be so, we may suspect 
one or other of several things. 

1. If the thief be a man between twenty-five and fifty-five, 
we may suspect him to be in a very early stage of general 
paralysis, in which acts of foolish and unprofitable theft are 
not unfrequently committed. Here, of course, we should look 
for the early symptoms of general paralysis, an incipient 
stutter, loss of memory, by which sometimes the so-called 



THE ACTS OF THE INSANE. 191 

thefts may be explained, the occurrence of epileptiform at- 
tacks, a general condition of exaltation, and ideas of being 
able to afford anything. 

2. We may meet with that form of insanity called moral, 
when the patient is either on the high road to general intel- 
lectual insanity, or, stopping short of delusions, shows his 
malady in insane acts which he justifies, in general altera- 
tion of character, and intellectual defect. 

3. The individual may be congenitally idiotic, or imbecile, 
or may become demented gradually, after reaching adult age, 
from brain disorder. This introduces us to a class of half- 
witted boys and girls, who go sometimes to jail, sometimes 
to an asylum, according to their good or bad fortune, friends, 
and circumstances. To lay down the exact amount of re- 
sponsibility of each of these is no easy task ; but one thing 
is certain, each case must be examined and considered by 
itself, in view of the general mental capacity, bodily dis- 
orders, and history. We shall gain no assistance from con- 
stituting out of these weak-minded people one special class 
of thieves. Whether their propensity is thieving, drinking, 
squandering their money, or frequenting the company of the 
lowest of the low, they must all be judged by their capacity 
of intellect, and not by their acts alone. 

4. With regard to acts of theft committed by well-to-do 
women in a pregnant state from supposed longings, I confess 
I should look upon any such with the greatest suspicion, 
unless there was other corroborative evidence of insanity. 
Stealing in shops is not very uncommon amongst ladies, if 
we are to believe what we hear. The impulse to appropriate 
an article, if it appears that it can be done with safety and 
secrecy, is one that is not seldom felt by many ill-regulated 
minds, and to erect this into insanity would be fraught with 
the greatest danger to society. Acts of violence are common 
amongst the insane; acts of secret and systematic theft are, 
in my experience, much less frequent, and other evidence of 
insanity should always be looked for. 



LECTURE IX. 

The two Extremes of Insanit}' — Acute Delirium and Acute Primary 
Dementia — Early Symptoms of Derangement — Treatment — Insanity 
with Depression — Treatment, Medical and Moral — Prognosis — 
Melancolie avec Stupeur. 

In this and the following lectures it is my intention to 
describe clinically certain patients who may come under 
your notice in ordinary practice. I shall portray their symp- 
toms, and, so far as is possible, indicate the treatment. I 
shall also endeavor to connect the symptoms with the patho- 
logical varieties of the disease previously enumerated. Con- 
cerning some, however, you will be consulted, not so much 
with a view to cure or treatment, as to elicit your opinion 
upon the question of their sanity or insanity. Of these I 
shall speak later; but first I propose to enter upon a descrip- 
tion of those forms of insanity which urgently demand med 
ical treatment, and which interest us as practical physicians 
and pathologists. As a rule, there is no difficulty in per- 
ceiving that the patients are of unsound mind ; the question 
is, are they curable, and how are they to be cured ? 

In what order am I to treat of these ? After examining the 
pathological phenomena presented in the full development 
of the disorder, I think that there are two forms which may 
be placed, one at either end of the scale, and that between 
these all the rest may be ranged. 

The patients I put at one end of my list are those suffer- 
ing from acute delirium — acute delirious mania — which runs 
a rapid course to death or amelioration in a week 

The two ex- . 

tremes of or fortnight. Here we see, for the time, entire sleep- 
lessness, incessant action of brain and body, with 



MELANCHOLIA. 193 

the evolution of great heat, speedy emaciation, a quick pulse, 
tongue coated and soon becoming brown, symptoms pointing 
to an excessive decomposition of every tissue, and a Acute 
general excess of brain action, which, if it does not delirium - 
cease within a certain time, leads to death by exhaustion 
without apparent morbid change. No other kind of insanity 
is so rapidly fatal, or calls so imperatively for medical treat- 
ment. 

At the other end of the list of cases I place patients suf- 
fering from what has been called " acute dementia." 

° Acute 

The name has been cavilled at, but it really describes primary 

. . 1 . dementia. 

the disorder, it we use the word acute in the sense 



of "recent," and "non-chronic." In such a patient we see 
almost the opposite of the former. There is not excess 
but defect of action and oxidation. The skin is cold, the 
hands and feet in hot weather are blue with cold, the pa- 
tient sits motionless, lost, answers no questions, does not 
appear to understand them, looks idiotic, sometimes almost 
comatose ; the pulse is very weak and slow, the tongue pale 
and moist, food is taken passively, and sleep is not absent. 
Such a case often resembles one of chronic dementia, the 
result of long-standing insanity, old age, or brain disease, 
and without a history we shall find it difficult to form an 
accurate diagnosis. However, I am not going to describe it 
in this place. As the very opposite of acute delirium I place 
it at the end of the scale, and between the excess of cerebral 
action and this extreme defect we may range all the varieties 
of disorder, and try to ascertain, both for the purposes of 
pathology and treatment, how far their departure in one or 
other of these directions corresponds to the mental symptoms 
exhibited. We shall, unquestionably, meet with cases that 
some would call melancholic, while others will think they 
ought rather to be termed maniacal ; cases that one person 
will call acute delirium, another acute mania. There will be 

13 



194 MELANCHOLIA. 

such on the border-land of all diseases, — cases of rheumatism 
that can hardly be called acute ; cases which one may term 
rheumatism, another gout; others which one calls typhus, 
another typhoid. Yet, speaking generally, we employ the 
names acute rheumatism, gout, typhus, and typhoid, not to 
describe a disease, but to denote a number of symptoms which 
usually coexist in the individual said to be suffering from it. 
In the same way we may use such terms as mania, melan- 
cholia, and dementia. These names do not, as some object, 
merely denote varieties of mental symptoms and delusions: 
acute dementia is pathologically a different disorder from 
acute delirium, occurring at a different age and running a 
different course. It is a malady of youth, while acute deli- 
rium attacks patients in the prime of life, and melancholia 
is most common in those whose vigor is on the wane. Each 
variety may be due apparently to a similar cause, as a fright 
or mental shock. Each may be idiopathic, that is, it may 
come on without assignable cause, owing to the inherited 
predisposition combined with some constitutional disturbance, 
but when developed they are different diseases, requiring dif- 
ferent treatment. 

I shall not, however, commence by a description of either 
of these extreme forms, but shall put before you the earliest 
indications of mental disorder, and trace their progress and 
development in various directions. In the exanthemata, in 
fevers and allied diseases, they are premonitory symptoms 
threatening approaching mischief, but not clearly indicating 
what it is to be, so that we say the patient is "sickening" 
for something, but cannot definitely say what; similarly, 
many signs of mental disorder make us apprehensive of 
coming insanity, but we cannot always say with certainty 
what form the malady will assume. Speaking generally, the 
more rapid the onset, the more acute are the symptoms, and 
the shorter the attack : that which gradually and insidiously 
comes on, gives us, it is true, a better chance of arresting its 



MELANCHOLIA. . 195 

progress short of actual acute disorder, but this, if reached, will 
probably be of considerable duration. 

It often happens that a patient is conscious of there being 
something amiss with him for a very considerable 
time before he says anything about it, or any of his to ms of 
friends notice it. Frequently friends, and relatives 
also, if they be not near relatives, are afraid of mentioning 
what they observe, even to the patient himself. This period 
of alteration precedes many forms of insanity, and I shall 
have again to allude to it. It is of the greatest consequence 
that treatment should be at once adopted, but often a long 
time elapses before the doctor hears of it — time which would 
have been most valuable in trying means of relief. Patients 
are sent to asylums whose insanity is stated to be of a week 
or a fortnight's duration, but who have been thought odd by 
servants or others perhaps for months. Many complain at 
first of confusion and dulness of head, of disinclination or 
inability to do their day's work ; often they suffer headache; 
almost always they sleep badly; periods of depression alter- 
nate with periods of excitement. If there be less and less 
sleep the advance will be rapid, the depression more marked, 
the excitement more irrational ; and now fancies, at first 
transient and recognized to be fancies, afterwards permanent 
and unmoved by the arguments and demonstrations of friends, 
vex and torment the patient, and drive him to acts of in- 
sanity. 

Of this premonitory stage, what is the prognosis and treat- 
ment ? Here the aid of the physician is sorely needed. What 
aid can we afford ? 

If we see the patient quite early, we may find, not exces- 
sive rapidity of pulse, but possibly slowness. Very likely it 
will not be more than fifty or sixty. We shall very 
probably hear of headache, or pains in the vertex 
or back of the head, together with constipation. I am now 
assuming that the sufferer is in that condition that he can 



Treatment. 



196 . MELANCHOLIA. 

inform us or his friends of what he feels; but not every pa- 
tient in this state will see a doctor. If a woman, there is in 
all likelihood some irregularity in the catamenial function. 
You inquire the cause of all this. There may be one, plain 
and palpable, as overwork, mental anxiety, a bodily illness, 
or pregnancy, lactation, or parturition. The cause may be 
removable or irremovable. And very probably you are in- 
formed of something which is not really the cause, though it is 
put forward as such by the friends ; you will have to inquire 
further before you come to a conclusion on this point. The 
cause may have already passed away — as parturition: you 
only have to deal with the resulting condition. If it be lacta- 
tion, you can end it; but if the patient be pregnant, you will 
have to nurse her through the period of gestation and par- 
turition, or will have to consider the question of inducing 
premature labor. Yet when the cause is removed, we do not 
always at once arrest the disorder: the mischief is lighted 
up in the brain, and must run its course. Frequently, how- 
ever, we may have the good fortune to restore the balance. 

The two things to be kept in view may be called, in con- 
cise terms, moral and medical treatment. We must inquire 
into, and, if need be, correct, the patient's external sur- 
roundings, and must, by diet and medicine, try to restore his 
physical health..,, (jn many cases, perhaps in most, it will be 
change of advisable to send him away from home — to pro- 
^ v scene. duce an entire change of ideas and objects — to re- 

move by this means painful subjects of thought constantly 
presented by the sight of home, or wife, or children^ subjects 
already, it may be, distorted by fancies, and incapable of 
being regarded in their true aspect. Then comes the ques- 
tion, where is he to go, who is to accompany him? Here 
difficulties arising out of the patient's circumstances, pecu- 
niary means, impedimenta of all kinds, may prevent us doing 
exactly what we wish. One thing is certain, — he should not 
go alone. Morbid fancies come thick and fast to a man who 



MELANCHOLIA. 197 

has no one with whom to interchange ideas. I lately saw a 
gentleman who had a transient attack of mania, and re- 
covered quickly in his own home. Six months after he went 
away by himself on a sketching tour, and though he was 
quite well at starting, his old fancies all came back to him in 
his solitude in about ten days, and he fled back to his friends 
to have them dispelled ; and happpily this was done. Who 
is to be the companion? Is the wife to go with the husband, 
the husband with the wife ? Who is to go with single people ? 
As to this there is no rule. The companion must be a per- 
son of sense and tact, and devoid of fear. Of this you must 
judge as best you can. If no one can be found fit for the 
post, the patient had better stay where he is. Where is he 
to go ? Not abroad : a trip to the Continent is all very well 
at the end of an illness, to give the finishing stroke to the 
cure ; but at the beginning, when we are uncertain what is 
about to happen, a patient should not go out of reach of as- 
sistance and immediate restraint and treatment. The place 
to which invalid Londoners and many others are chiefly sent 
is the seaside, but I do not find that sea air is beneficial to 
those threatened with insanity. I have seen so many get 
rapidly worse after a few days' sojourn at Brighton, that I 
cannot help coming to the conclusion that there is something 
about the seaside which tends to convert the preliminary 
stage of confusion and depression into wild excitement ; and 
for this reason I prefer to send patients for change to an in- 
land place. What can we do in addition to avert 
the evil that threatens our patient's reason? First, 
with regard to diet : assuming that the incipient symptoms 
of insanity are those of deficient nerve-force, I inquire closely 
into the eating and drinking of the patient, and constantly 
find that, whatever may be the proportions of the latter, the 
former is in defect. Mental trouble or bodily ailment, fears 
of dyspepsia, anxieties about liver and constipation, have 
caused the amount eaten in the day to fall below the normal 



Food. 



198 MELANCHOLIA. 

standard, often to a very considerable extent. Thus, for lack 
of nourishment the brain becomes more and more exhausted, 
just at the time that it ought to have an extra supply. Regu- 
laritjr in meals, by which I mean the eating an adequate 
quantity at regular intervals, and not allowing a very long 
period, even at night, to elapse without food, often does much 
good ; for we constantly find that before any mental symp- 
toms have been observed, the patient's friends have noticed 
that he has grown thinner. Malt liquor, wine, and the morn- 
ing beverage, rum and milk, may be given as you see fit; 
but I attach more importance to the administration of good 
and wholesome food in this stage than to stimulants, which 
in many produce heat and pain of head, or undue excite- 
ment. 

If sleep be insufficient and irregular — and you will rarely 
find it otherwise — are you to give medicine of any 

Medicines. . . 

kind? At this time I think and trust that we shall 
derive valuable assistance from the hydrate of chloral. I 
have known more than one threatened attack of insanity 
warded off by its administration in the premonitory stage of 
sleeplessness, and I would make trial of it in preference to 
opium in any form. For the latter, as you well know, not only 
procures no sleep for some people, but absolutely prevents it, 
and by raising the bodily temperature causes the very symp- 
toms we are endeavoring to dispel. At a later period it is 
often of the greatest service, but at the commencement it is 
hazardous to try it, and chloral is not attended with the same 
disadvantages, and in a mild attack is far more sure in its 
action. Should this fail, you may try bromide of potassium, 
or extract of henbane, or tincture of digitalis ; but assuredly 
chloral should be given first, in doses of twenty-five or thirty 
grains. Tonics may be required, — iron, quinine, arsenic, or 
strychnia. There is nothing special to be said concerning 
these, which must be left to your discretion and judgment. 
Patients at this time are not capable of great fatigue, mental 



MELANCHOLIA. 199 

or bodily. If sent into the country, very hard exercise — as 
boating or very long walks — must be interdicted. I have 
known it produce suddenly a very acute attack. Neither 
must they be exposed to great heat of sun. Amusement 
they require, not work, and this must be regulated by the 
companion, without whom, as I have said, they are not to 
be trusted, and who is to have supreme authority in every- 
thing. In some such fashion many a threatened attack of 
insanity may be cut short or warded off. 

Instead of subsiding, these symptoms may be the precur- 
sors of the severe and obstinate insanity which T hesymp- 
requires to be treated under the restraint of an * omsma >' 

A become more 

asylum or a quasi-asyluin. Whether coming on serious, 
suddenly, or gradually developing during weeks or months, 
it may reach those stages which in everyday parlance are 
called mania, melancholia, acute mania, acute melancholia, 
acute dementia, or general paralysis; for at the very begin- 
ning even the latter may present the same indications as 
other forms of derangement. Now, whatever be the cause, 
and whatever pathologically may be the variety of the in- 
sanity, we shall find practically that it may be ranged under 
one of these classes ; though, as I said, cases do occur which 
seem to be on the border-land, rather than to fall completely 
within one of them. Yet typical cases of melancholia — of 
acute, noisy, conscious mania — of acute delirium — of general 
paralysis, — are so well marked, that if accurately described 
they cannot fail to be recognized, and they serve as a basis 
from which to consider the less defined and more doubtful 
cases. But we must recollect that the attack is determined, 
whatever its origin, by the constitutional peculiarities of the 
individual, so that he may suffer at one time from melan- 
cholia, at another from mania, at another from acute mania, 
according to the greater or less lack of nerve-force, or the 
greater or less irritability of his nerve-centres. 

The insanity which gradually develops after a long period 



200 MELANCHOLIA. 

of incubation is at first marked by depression : afterwards the 
depression may pass away, and excitement of a fearful, angry, 
or even hilarious character may take its place ; or the depres- 
sion may increase until it becomes silent and settled melan- 
cholia or panic-stricken frenzy. 

I propose, in the first place, to speak of the forms of in- 
insanitywith sanity attended by marked depression, such as are 
depression, generically termed melancholia. They form a well- 
defined group, distinguishable in many respects from other 
varieties, requiring different treatment, and attended with 
different results. The melancholy character is appparent 
throughout, whether the patient is only slightly and tempo- 
rarily depressed, or is raving in excited terror, and trying 
with might and main to escape from the horrors of impending 
torment. 

The simplest form of melancholia is that feeling of depres- 
sion which assails most men at some time of their lives, and 
is generally attributed to dyspepsia, or the liver, or relaxing 
climate, or may be caused by difficulties and disasters. Some 
men feel it frequently ; in some it lasts for a few hours only, 
in others for days; some may require treatment in order to 
disperse it, in others it passes away of itself. I have already 
glanced at this in its simple and premonitory stage, and have 
suggested what ought to be done by way of treatment. I am 
now about to consider those cases which have not been cured 
by the treatment already spoken of — change of scene, the 
companionship of a friend, fresh air, and good diet. I assume 
that the depression has become undoubted insanity, leading 
to ideas and acts of an insane character, and requiring special 
interference and constant medical care. What are the most 
prominent symptoms of the disorder? 

The patient is in a state of general depression. An utter 
lack of energy is exhibited in all his ideas, feelings, 

Delusions. * __ . _. . 

and acts. JNot only has he many insane delusions, 
but he takes a desponding view of everything that happens 



MELANCHOLIA. 201 

around him, and connects his own position and fancied 
misery or wickedness with all the disasters that he reads of 
in the papers, or hears in his own circle. The most distant 
events, earthquakes abroad, shipwrecks at sea, battles and 
murders, all depend on his evil fortune, or have happened 
for the express purpose of making his lot more wretched 
than before. He would give himself up to the police for the 
committal of all the murders he reads of, or would flee away, 
and hurry from place to place to escape those who are ac- 
cusing him of crimes that never have been committed. Or 
he has committed sins so black, so unpardonable, that he 
dreads not human, but divine justice : his soul is lost beyond 
chance of redemption; he is without hope in the world. 
Again, he is beggared in fortune, his wife and children are 
going to the workhouse, he is to be arrested for debt. Then 
his health is in as sad a state as his affairs. He is eaten up 
with syphilis, his inside is all gone: he has in him a burn- 
ing fire consuming his vitals, and reducing his excreta to 
cinders; he has the leprosy of the Old Testament: a loath- 
some smell emanates from his body, and contaminates every 
chair or sofa on which he sits. No amount of argument, no 
demonstration, however plain and undeniable, shakes his 
conviction or banishes his fears. These are to be removed by 
medical treatment, not by any method of moral persuasion. 

If we examine his appearance and bodily condition, what 
do we find? His aspect is dejected, dull, and heavy, or woe- 
begone to an extremcdegree. He sits or stands in one place 
for hours,, or constantly tries to wander away. He is, in all 
probability, much thinner than usual. He sleeps badly, and 
eats little; the tongue is foul, coated, and creamy, the bowels 
obstinately constipated, the breath offensive, the pulse slow 
and weak. 

Now, among which of our pathological varieties are we to 
look for these melancholic patients? Chiefly we climacteric 
find them among those who are passing into the mdancholia - 



202 MELANCHOLIA. 

decline of life, whose insanity has been termed " climacteric." 
We do indeed see melancholia in patients of all ages, and 
see it accompanying all causes and conditions; but it is the 
exception to find it in the young, the rule to find it in those 
whose vigor is beginning to fail, whether at forty, fifty, or 
sixty years of age. Of 338 cases of melancholia admitted 
into St. Luke's Hospital, only 9 patients were below the age 
of twenty. Occasionally it occurs after parturition in women 
who have been much weakened by their confinements. The 
insanity which appears some weeks after confinement gene- 
rally takes this form, and often rises to a very acute state, 
with sleeplessness and obstinate refusal of food. The weaker 
the patient the more urgent are the symptoms, and the greater 
the need for active and immediate treatment. There is 
nothing of the sthenic character which marks the wild ex- 
citement of mania. It is not usually found in phthisical 
patients who are commonly excited and maniacal, but we 
sometimes see it thus associated. It is an old belief that it 
is connected with the abdominal organs, as the liver; or, 
according to Schroeder van der Kolk, the colon ; but there 
seems reason to doubt this. The disorder of the liver and 
the loaded state of the colon are as likely to depend on the 
general derangement of the nervous system as to be the 
cause of the mental disorder. The question is not set at rest 
by their vanishing together. The propter hoc in such cases 
is very hard to come at. 

Whatever be the cause of the insanity, whether we call it 
idiopathic or sympathetic, phthisical or sexual, or even para- 
lytic, the melancholia is the effect and indication of the con- 
dition of the sufferer at a particular time. He is generally 
depressed, his slow and feeble circulation imparts little force 
to his brain-centres, and the supply there is always in defect. 
Not only is it in defect — for this appears to be the condition 
of almost every phase of insanity — but there is little action 
going on. The metamorphosis is not rapid ; there is no im- 



MELANCHOLIA. 203 

mediate danger to life, emaciation does not occur rapidly as 
in acute mania. The patient is not absolutely sleepless, 
though he may sleep little. This depressed state may last 
for years and then pass away ; and, so soon as the feeling is 
gone, all the delusions and fancies bred of it vanish too. We 
are far from understanding the exact pathology of that state 
which gives rise to melancholic feeling. I have known it to 
exist in a gentleman who ate heartily, who was stout in body 
and florid in face, who was free from all bodily disease. In 
him it appeared without assignable cause, and in process of 
time it vanished ; and all that we can say of such a case is, 
that by some concurrence of conditions beyond our recogni- 
tion, the nerve- power of this man's brain was insufficiently 
produced. 

We find patients whose melancholic delusions are attended 
with so much excitement that they may rather be called 
maniacal. This only indicates that their condition, though 
one of depression and defect, is at the same time one of 
greater disturbance of the brain and more rapid metamor- 
phosis; and, as we shall see, when it attains a certain height, 
it becomes as formidable and dangerous a disorder as any 
other acute form of insanity. 

But here I wish to point out the treatment of an ordinary 
case of melancholia, attended with great depression Treatm ent of 
and melancholic delusions, disinclination to take melancholia - 
food, little sleep, and obstinate constipation. 

The first thing you are to remember is, that every patient 
of this kind is to be looked upon as suicidal. Never suicide to be 
mind whether he has, or has not as yet, made at- a PP rehended - 
tempts, or shown signs of such a disposition. He may have 
had no opportunity, or he may have never yet felt the par- 
ticular idea or impulse. But this is the description of pa- 
tient who jumps out of window, or into the river. Nay, 
he may commit suicide in even an earlier stage, before his 
friends have noticed anything like delusion, when "they only 



204 MELANCHOLIA. 

thought him a little low," and were afraid to take any meas- 
ures for his safety, "for fear of worrying him." Hundreds 
and hundreds of inquests are held upon patients of this kind, 
who, by the commonest care, might have been successfully 
treated and cured. 

Where is the treatment of such a patient to be carried 
out?] An asylum is not absolutely indispensable, if the 
patient's means will afford him what he requires elsewhere. 
If a poor man, there is nothing for it but to send him to an 
asylum, i For he must not be left for a moment where he 
can do himself harm, or make his escape. He requires the 
companionship of some person his equal in education, as 
well as of attendants; Unust be removed from home to a 
house, airy, light, and quiet ; and should have facilities for 
taking exercise without going into crowded thoroughfares^ 
All this implies some considerable expense. [If, as I say, his 
means suffice, such a plan often works a cure more rapidly, 
in my opinion, than the asylum, with its depressing influ- 
ences, and lack of sane, companions ; but if funds are scanty, 
the latter is a necessity^ for the other plan is impracticable 
unless carried out completely in all its details. 

Having removed your patient into a suitable abode, and 
having arranged that he shall never be left alone 

Medicines. „ 1 tip 

tor a moment, what are you to do by way of treat- 
ment ? Your object is to restore the defect of brain by 
means of food and sleep, and you will find that in many 
cases a most satisfactory result follows the treatment, and 
this in no long time. I have seen some very bad cases re- 
cover perfectly in two months, and recover in a manner 
which was clearly due to the medical treatment, and not to 
mere change of scene and surroundings ; for this had been 
already tried, and tried in vain. 

Besides the mental symptoms, there are three things spe- 
cially to be attended to, — the want of sleep, the tendency to 
refuse food, and the constipation. 



MELANCHOLIA. 205 

Chloral will produce sleep in these cases, as in others; but 
is better suited to the excited than the depressed forms of 
insanity. It is a sleep-compelling agent; beyond that its 
effect seems of little import. It does not appear to have 
such a healing influence as opium where the latter is bene- 
ficial. In violent and excited cases of acute melancholia, 
chloral can be given with benefit; but in subacute melan- 
cholia, the preparations of opium are of great service, whether 
given by the mouth or by subcutaneous injection. I have 
very rarely been obliged to discontinue them, and have 
almost invariably found the patient mend after their admin- 
istration. The preparation which has, according to my ex- 
perience, succeeded best is the liquor morphias bimeconatis, for 
it does not cause sickness or constipation, which too fre- 
quently follow the administration of the acetate or hydro- 
chlorate of morphia. As the patient is already inclined to 
refuse food, often on the plea of nausea or loss of appetite, 
and as his bowels already are obstinately constipated, it is 
important that we do not increase this state of things by our 
remedies. Dover's powder, in some cases, or solid opium, or 
Battley's solution, we may give, and give freely, in full doses 
at night, and in smaller doses two or three times a day. It 
is of little use to give at night by the mouth less than the 
equivalent of half a grain of morphia. 

We now come to the food question. We read that patients 
refuse their food because of dyspepsia, and that the 
latter is indicated by the foul, coated tongue, fetid 
breath, and loaded bowels. I am obliged to say that I think 
all the symptoms of dyspepsia are the result, and not the 
cause, of the depressed nervous condition; that the tongue 
is covered with old dead epithelium, which, for the same 
reason, is not thrown off ; that the fetid breath is caused by 
this, or is due to actual starvation ; and that the loaded 
bowels must also be ascribed to the want of general power. 
And I say this with some confidence, having treated a very 



206 MELANCHOLIA. 

considerable number of these cases, and having removed all 
the symptoms by means which were in no degree directed to 
cure dyspepsia. This is the kind of diet which I have fre- 
quently given for the purpose. Before getting out of bed 
in the morning, rum and milk, or egg and sherry; breakfast 
of meat, eggs, and cafe au lait, or cocoa; beef-tea, with a 
glass of port, at eleven o'clock ; and a good dinner or lunch 
at two, with a couple of glasses of sherry ; at four, some more 
beef-tea, or an equivalent ; at seven, dinner or supper, with 
stout and port wine ; and at bed-time, stout or ale, with the 
chloral or morphia. This allowance I have given to patients 
who were said to be suffering from aggravated dyspepsia ; 
who, I was told, had suffered from it all their lives; who 
had never been able to take malt liquor, or eat more than 
the smallest quantity at a time ; who, in fact, had constantly 
been living on about half the quantity requisite for their 
support, and through chronic starvation, had come to this 
depressed condition. I need hardly tell you that the patients 
and their friends were aghast at the quantity ordered to be 
taken ; but improvement has taken place immediately, the 
tongue cleaned, the constipation given way, and the depres- 
sion diminished; and I have known patients' themselves 
become so convinced of the necessity of this augmented diet, 
that after recovery they have continued to take about twice 
as much as before the illness. How dependent these melan- 
cholic patients are upon food has often been proved. Some, 
when nearly well, if they were out for their walk or drive 
longer than usual, or from any other cause postponed their 
meal, felt at once a return of the depression and delusions, 
which vanished again after the reception of food. 

I am speaking now of patients who would refuse their 
food if left to themselves, or protest against it, but who take 
it when told to do so, or allow themselves to be fed without 
downright resistance. Wherever you can, give solid food ; 
do not be content with beef- tea and stimulants, which are 



MELANCHOLIA. 207 

supposed to be the sole diet suited to invalids. The best 
proof that dyspepsia has nothing to do with these patients' 
condition is, that even with this enormously increased diet, 
I never knew any reject it from the stomach, except one 
lady, who did it wilfully ; when made to take another supply, 
she kept it down. You may vary the diet to any extent, 
for every kind of good, plain, nourishing food may be given 
— poultry, game, fish — not merely mutton and beef. But 
even turtle-soup and champagne are not to take the place of 
solid food, which is a far better sedative than mere liquids. 

The constipation will often be remedied by the stimulus 
of the increased amount of food ; but when the patient is 
first subjected to treatment, the colon is often clogged by 
hardened masses of fasces, which nothing but enemata will 
remove. You may use for this the enema (ereblnihince of the 
Pharmacopoeia, with or without cnstor-oil, and the operation 
will probably have to be repeated more than once After- 
wards you may promote regular action of the bowels by 
giving a daily dinner-pill of the watery extract of aloes, or 
by a daily teaspoonful of castor-oil, or some such laxative. 
Active purgation only makes matters worse, and should be 
avoided. I have also found great benefit from giving such 
patients bran-bread. This has been called a cure for melan- 
cholia, and it certainly brings about a regular action of the 
bowels in persons who for years have never been relieved 
except after medicine. 

Melancholic patients are almost invariably better towards 
evening, and worse on first rising in the morning, owing, in 
my opinion, to the long abstinence from food. When a patient 
habitually wakes after three or four hours, and cannot go to 
sleep again, some food, as a sandwich, glass of sherry, or some 
of his matutinal rum and milk, will often bring sleep back to 
him. If this fail, he may take a small dose of chloral. 

These people all suffer much from cold, are generally worse 
in the winter, often lingering through the spring, and wait- 



208 MELANCHOLIA. 

ing for hot weather to thoroughly restore them. They will 
derive benefit from the hot-air or Turkish bath, if they can 
have it regularly, and in all respects they require warmth. 
Their rooms should be sunny, and their clothing sufficient. • 

Of course, in such cases moral treatment is not to be lost 
Moral treat- sight of ; and although no precise rules can be laid 
ment " down on this subject, yet the recovery of a patient 

may be greatly aided by the judicious care of those about himj 
Every one must be struck by the intense self-feeling of the mel- 
ancholy man. His egotism exceeds even that of the paralytic 
or maniac. He thinks that everything is centred in him, 
that he has done the greatest sins, or is to endure the greatest 
torments. His superlative misery is a theme on which he 
loves to descant as much as the paralytic loves to describe 
his wealth and greatness. His depression is great, but he 
magnifies it in the recital of his woes. /'Therefore it is neces- 
sary to lead him away from his self-contemplation, and to 
awaken in him an interest in others ; and it is curious and 
interesting to see the gradual improvement in this respect 
By degrees he will listen to news told to him, or to whafi^ 
mentioned in his presence. He will furtively look at letters 
or the newspapers, and in this way, little by little, return to 
his normal state. Many a patient has been suddenly cured 
of melancholy by some event which called for immediate 
action. Thus, a lady's only son was seized with a dangerous 
illness, and she was obliged to go and nurse him. In her work 
and anxiety she forgot her own melancholy, and when he 
recovered she too was well. Melancholy is banished in this 
way when the patient is on the road to recovery; but at the 
commencement of an attack, before the strength is restored, 
we are not to expect such a sudden termination. 

What is the prognosis in these cases of subacute melan- 
cholia? Generally very good. In my experience 
almost every case of this kind, if it does not run on 
to acute and excited panic-stricken frenzy, with desperate 



MELANCHOLIA. 209 

determination to resist food, and total want of sleep, pro- 
gresses to a favorable termination in a longer or shorter 
time, whether in or out of an asylum. Of former patients 
now at large and well, more have suffered from melancholia 
than from any other form of insanity, and some of these were 
inmates of asylums for long periods. In the second volume 
of the St. George's Hospital Reports, I have given an account 
of three patients who recovered after long treatment in 
asylums. One was a gentleman who thought he had com- 
mitted the unpardonable sin — nay, that he was himself the 
devil. He also thought himself ruined and afflicted with 
leprosy, but did not refuse food. He went on in this way for 
seven years, till at last affairs necessitated action on his part, 
and he woke up out of his melancholy, and has since keenly 
enjoyed life and its pleasures. Another was a lady of fifty- 
six years of age, who had all the worst symptoms of melan- 
cholia, refused food, did not converse, but paced her room, 
ejaculating " My God, my God," and picked and rubbed her 
hands in terror and panic till they were sore. After five 
years she began to mend, gradually improved, and in six 
months was discharged quite well. Another was a gentle- 
man, aged thirty-one, who had been in an unhealthy tropical 
climate. He had all the symptoms of melancholy, was 
suicidal, tried to avoid food, would not converse, but mut- 
tered to himself, and thought he was going to be put to death 
for murder and forgery. He too recovered perfectly, after 
being in this state for five years. 

I believe that depression is the only form of insanity in 
which we may expect recovery after such a period as seven 
years, and we may perceive in such recovery an indication of 
the pathological state of the patients. It would appear that 
during the whole of the period the general nerve-energy is 
in a state of defect, the result of which is, first, the feeling 
of intense melancholy ; secondly, ideas and fancies — in other 
words, delusions — growing out of the feeling. All the ideas, 

14 



210 MELANCHOLIA. 

in fact, are tinctured by the prevailing gloom. But if the 
nerve-force is restored, if the physical condition of the brain 
is raised again to its normal level, all such delusions vanish, 
the abnormal feeling passes away, and the mind resumes its 
proper work unimpaired by what it has gone through. 

In dealing with cases of this kind, it is important, for 
many reasons, that we should keep before us the possibility 
of recovery after a long period. For our opinion will be 
asked by those who, having the disposition of property, may 
regulate their wills by what they hear of the chances of the 
patient's recovery. I always advise that even an inquisition 
in lunacy should in these cases be deferred as long as possible, 
to give time and opportunity to see what the probable dura- 
tion of the disorder will be. But a commission in lunacy 
can be superseded, and the patient restored to the manage- 
ment of his affairs. A will, however, is another matter; the 
testator may die, and soon after the lunatic may recover 
from his melancholy to find himself disinherited. 

If the patient gets worse, and his melancholy increases, it 
will take one of two directions. Either he will sink into 
profound dejection, and, speechless and motionless, will sit 
all day, lost to everything around him, and apparently re- 
gardless of what is said or done; or he will become more 
and more panic stricken, till in a wild frenzy of excitement 
that may almost be called mania, he tries to rush away he 
knows not whither, or struggles against the efforts of those 
around him, all of whom are in his eyes about to torture or 
drag him to prison or destruction. The first of these forms 
Meiancoiie is termed by the French melancholic avec stupeur, 
avecstupeur. anc [ j s described as a special variety of insanity. 
It has also been confounded with another form, of which I 
shall have to speak hereafter, viz., acute dementia. If, how- 
ever, we consider w T ell this melancholic avec stupeur, we shall 
see that it is merely an advanced, stage of that dull silent 
depression, which is the ordinary type of melancholic in- 



MELANCHOLIA. 211 

sanity. Of its treatment little need be said. Such patients 
are generally manageable and passive in the hands of those 
about them. They must be fed, but do not violently resist. 
They require to be led about for exercise, to be washed and 
dressed. Though they sit motionless for hours, they are not 
to be trusted alone, for they may eagerly avail themselves of 
an opportunity to commit suicide. They demand even more 
food and stimulants than those who suffer from the milder 
forms of depression, and must be kept as warm as possible, 
for their motionless condition does little to circulate the 
blood stagnating in their vessels. 

Writers have speculated upon what is passing in the mind 
in this state of stupor, on the absence of will, on the halluci- 
nations and illusions that torment the patient. Our infor- 
mation must necessarily be derived from the patient himself 
after recovery, and it must needs be that such testimony is 
very fallacious. In fact, it is just as trustworthy as an 
account of the whole psychological state of a man in sleep 
derived from what he himself recollects of his dreams. 
There is, however, a very close resemblance between the 
dreaming condition and profound melancholy. That which 
is going on around the patient is observed through the 
medium of the depressed feeling, and is altogether unreal 
and illusional. All people are changed, and places, and things; 
and, pathologically, the states of the dreamer and the melan- 
cholic are probably nearly akin ; for in dreams it would ap- 
pear that the brain is only partially at work, that the whole 
of the idea organs are not in a state of activity, but only a 
few, therefore there is no correction, but all seems real. Simi- 
larly the nerve-power in melancholia is so low that the entire 
idea-faculty of the brain cannot be employed. The depressed 
condition influences the ideas that are at work, and these are 
not corrected by the entire brain as they would be in health. 
The sensations experienced from affections of the skin or vis- 



212 MELANCHOLIA. 

cera are converted into flames, tortures, snakes, and so forth, 
just as in dreams cold feet make us think we are walking on 
ice, or dyspepsia originates ideas of legions of devils. These 
melancholic patients, though they present the appearance of 
stupor, sleep very little, and require chloral or morphia as 
much as the last mentioned class. 



LECTURE X. 

Acute Melancholia — Symptoms — Refusal of Food — Forcible Feeding by 
Various Methods — Drugs — Turkish Bath — Prognosis — Acute Pri- 
mary Dementia — S3 r raptoms — Diagnosis and Prognosis — Treatment. 

I have been speaking hitherto of patients suffering from 
what may be called subacute melancholia, who require con- 
stant watching, but who are not violent, do not resist feeding, 
and are, in fact, sufficiently tractable to be kept till cured in 
an ordinary house, if there be means adequate to their neces- 
sities. Such generally recover, but I am now going to speak 
of some who do not stop in a quiet stage of melan- AC ute melan- 
choly, but go on from it to an acute condition, of cholia - 
which the prognosis is the very reverse of favorable. 

This form of acute melancholia demands as much as any 
the care of an asylum. It is hardly possible to keep 

. Symptoms. 

a patient m safety in any ordinary house, or to treat 
him with any but the large staff of officers which an asylum 
supplies. He is not in a state of mere depression or mild 
melancholy, nor in silent stupor, but he is panic-stricken. 
In violent frenzy and terror he paces the room, dashes at the 
doors or windows, eager to escape from the doom that awaits 
him, from the police who are on his track. He will not sit 
on a chair or lie still on his bed, but is incessantly running 
about, exclaiming that he is going to be burnt or tortured, 
that the room is on fire, the floor undermined, and everything 
ruined and lost. He is suicidal in an extreme degree, and 
may try not only to put an end to himself, but also to harm 
himself in every way he can, to gouge out his eyes, cram 
things down his throat, swallow nails or bits of glass, or break 



214 ACUTE MELANCHOLIA. 

his legs or arms in the furniture. Though he will not attack 
others like a dangerous paralytic, he nevertheless resists with 
the utmost violence all that is done for him. He will take 
no food, will wear no clothes, will not be washed, neither will 
he remain in bed. This is a condition very different from 
that last described. It implies a much lower degree of nerve- 
force, and a much more serious disorder of brain, and the 
hopes to be entertained of cure are but small, if these patients 
remain in this state beyond a very few days, for they are 
generally broken in health before they reach it. Often they 
are advanced in life, or enfeebled by other diseases, and mel- 
ancholia is in them the commencement of dying, the later 
stages bringing not unfrequently gangrene of the lungs, or a 
condition closely resembling scurvy, indicating a gradual ter- 
mination of the vitality of the whole bodily frame. 

Such patients refuse food, not with a passive resistance like 
Refusal of the former, who allow themselves to be fed with a 
food. spoon, but wdth all their might, ejecting it from their 
mouths, even after we have managed to place it there. They 
drive us to the adoption of forcible alimentation, about which 
I must say something. We are not to wait long before we 
have recourse to this. They sink rapidly if not fed, and the 
more they are weakened by lack of food, the more are all 
their symptoms exaggerated. It is of no use to let them go 
for a day with a mouthful or two, neither can we afford to 
let them wait till they are hungry, or are in the humor to eat. 
The case is too serious, and too much is lost by abstinence, 
even for twenty-four hours. In the case of some insane per- 
sons there is no occasion for hurry. When they are tolerably 
strong and vigorous, and when the refusal of food is due to 
mere opposition or whim, we may wait, and frequently the 
humor will change, and they may be coaxed into taking food. 
But coaxing does little with the terror-stricken melancholic. 
Nevertheless, it must be tried. It is an old suggestion that 
the persuasiveness of the opposite sex may prevail upon pa- 



ACUTE MELANCHOLIA. 215 

tients to eat, that female friends and nurses should try to 
overcome the fears and reluctance of men, and males that of 
the women. In some forms of insanity this plan unquestion- 
ably is of service, but here I fear we shall find it of little use. 
The sufferer is determined not to eat, and will sink rather 
than do so ; in fact, the refusal is generally from a suicidal 
motive. Now comes the question, How are we to feed such 
a one ? Various authors advocate various plans of feeding, 
either through the nose, or through the mouth, with or with- 
out a tube passed down the oesophagus. Of these, Forcible f ee d- 
I would say that no one is suited to all cases, that ing - 
each has its merits and demerits ; but that if I were compelled 
to choose one, and one only, I would select that of the ordi- 
nary stomach-tube passed into the oesophagus through the 
mouth. Many advocate feeding by a spoon through the 
mouth, the patient being held on his back by attendants, and 
his mouth forced open for the purpose. The objection to this 
plan, in my opinion, is the length of time it takes. We are 
dealing with people who are extremely weak and prostrated, 
but who, nevertheless, resist violently ; and if the struggle is 
prolonged for half an hour, the patient loses as much through 
fatigue as he gains by the food ; yet when the struggle is not 
great, when food can be got down easily by this method, and 
when he swallows readily the food once placed in his mouth, 
there is no necessity for the stomach-pump, and he may be fed 
four or five times in the twenty-four hours. I feel bound to 
describe to you the various methods, that you may be prepared 
to adopt one or other as circumstances or opportunity indi- 
cate. Feeding may be accomplished by the mouth without 
the introduction of any tube. This plan is set out Byn]( , 11]30fa 
by Dr. S. W. D. Williams, of the Sussex Asylum, Sl " ,,m 
in a paper in the "Journal of Mental Science," October, 1864, 
and this is his plan of procedure: 

" With the aid of three attendants the patient is placed 
on his back on a mattress on the floor, and covered by bed- 



216 ACUTE MELANCHOLIA. 

clothes, being, as a sine qua non, in his nightdress as far as the 
armpits, the arms being free. The head rests on a well-filled 
bolster, an attendant kneels on each side of the bedclothes 
covering the patient, and thus easily but effectually secures 
the body. One hand is placed on the patient's wrist, and 
the other presses down the shoulder. By these means he is 
perfectly restrained in the least irksome way to both patient 
and attendant, and, which is of primary importance, but few 
if any bruises need be inflicted. Hold a person in any other 
part of his body, or by any other means, and he surely be- 
comes covered, after a few operations, by a mass of bruises, 
which often leads to unpleasant recriminations and fancies 
on the part of friends and relatives, and tends to foster the 
prevailing ideas current among the many as to the manage- 
ment of institutions for the insane — ideas which it behooves 
every conscientious alienist physician to persistently endeavor 
to dissipate, if he would wish to hold any claims to philan- 
thropy. The operator kneels at the patient's head, and if 
the patient is very restive, may steady his head with his 
knees; but this is seldom necessary. A third attendant takes 
his place at the operator's left elbow. It should be here ascer- 
tained that the patient's throat is quite free externally from 
any clothing. The next operation is to get the spoon into 
the patient's mouth : this, if the patient be a woman, is gen- 
erally easily done by getting her to talk, and slipping it 
in when the mouth is opened to speak ; this device failing, 
however, persistent but moderate pressure with the spoon 
against the teeth, aided, if necessary, by inserting a finger 
between the upper and lower gums behind the last molar, 
will soon effect our object. Of course, in putting a finger 
into the mouth, one must look out for being bitten ; but if 
the spoon be firmly pressed against the teeth so as to slide 
between them immediately the masse ters are relaxed, such 
an accident cannot readily occur. The best spoons to use are 
the small iron ones, to be found in most of our large asylums, 



ACUTE MELANCHOLIA. 217 

with the handle straightened. This should be placed far 
enough into the mouth to command the tongue, care being 
taken not to excite the reflex action of the fauces. It should 
then be restrained by the thumb and index finger of the left 
hand, the palm and remaining fingers firmly grasping the 
chin and preventing any to-and-fro or lateral motion of the 
head. The third attendant now passes his right hand under 
the operator's engaged arm, and firmly closes the nostrils, 
leaving his other arm free for any emergency that may 
arise. The operator can now with his right hand pour the 
food into the patient's mouth, and, provided the spoon well 
commands the tongue, deglutition is easily and perforce ob- 
tained, even in the most obstinate cases ; but the patients 
are really by this means so completely mastered that the 
majority of them drink the food down easily, and often the 
spoon is not required at all, but the nostrils being closed, the 
lips may be separated and the food poured into the mouth 
without opening the teeth. Indeed, for the first three weeks 
of last January, I fed a young lady in this way four times a 
day, although she was obstinately bent on refusing food. 
The most convenient instrument for containing the food is a 
gutta-percha bottle or ball holding about half a pint, and 
having for a stopper a bone tube like the extremity of an 
enema tube. This bottle can easily be commanded in the 
hand, and the bone tube having been inserted into the hollow 
of the spoon as it is held between the teeth, after a little prac- 
tice, by squeezing the bottle the quantity of fluid to be in- 
jected can be judged to a nicety, and the tube removed after 
each injection. Not more than half an ounce should be in- 
jected into the mouth at once, one good respiration being 
allowed between each mouthful. After an expiration there 
is a short pause before the next inspiration, and if this 
moment of rest be chosen for filling the mouth, there is but 
little likelihood of the larynx being irritated by particles 
getting into it and delaying the operation by causing a fit of 



218 ACUTE MELANCHOLIA. 

coughing. By a careful compliance with these rules, and a 
little practice, any one may administer, in all ordinary cases 
at least, a pint of liquid in from ten to fifteen minutes, with- 
out a possibility of any danger or harm accruing, which can- 
not be said of the various other modes in vogue." 

This is, in other words, the ordinary attendants' mode of 
feeding a patient: place the patient on his back, support his 
head, hold it between the knees, force open the mouth and 
keep it open, usually with a u forcing-stick," pour in a mouth- 
ful of liquid, and hold the nose till it is swallowed. It is a 
very simple plan, which succeeds well, as Dr. Williams says, 
" in all ordinary cases," especially where the patient is by it 
"completely mastered," and takes the food quietly when 
placed in his mouth, but it fails in extraordinary cases. If we 
meet with a very powerful patient, two attendants will never 
keep him quiet, and in the struggle his arms, to say nothing 
of body and legs, will present the mass of bruises Dr. Wil- 
liams so rightly deprecates. Then, as the mouth is held 
open all the time, the patient can eject by an expiration 
some, at any rate, of the fluid, and if he holds his breath as 
long as he can at each mouthful, the administration of a pint 
of liquid will occupy much more than fifteen minutes. The 
food being only placed in the fauces to be swallowed as res- 
piration demands, some of it does always go the wrong way, 
and great is the coughing and choking produced thereby. 
Frequently more is wasted than taken in this way; never- 
theless, it is well suited for many cases, and may always be 
tried before resorting to more instrumental means. Some 
use a funnel inserted behind the teeth ; others a glass bottle 
with a valve controlled by a spring, on which the operator 
places his thumb, and by which he can let flow as much or 
as little as he likes. A bottle of this kind made by Coxeter, 
called Dr. Paley's feeding apparatus, has a flat metal mouth- 
piece which keeps down the tongue, and through which the 



ACUTE MELANCHOLIA. 219 

fluid escapes. It is a most excellent contrivance y and by it 
many patients may be fed frequently and satisfactorily. 

Much the same plan has been recommended by Dr. Moxey, 
in the "Lancet," March, 1869, the only diiference being 
that, instead of putting the food into the fauces through the 
mouth, he pours it through a funnel placed in one of the 
nares. 

In the fourth volume of the "Journal of Mental Science," 
is an interesting paper by Dr. Harrington Tuke, By thenasai 
who reviews the various methods of feeding, and tube - 
gives the preference to an oesophageal tube introduced 
through the nose and reaching the stomach. Dr. Tuke 
speaks strongly against the plan of forcibly feeding by a 
spoon or funnel. " It is not only the violence that must 
accompany the administration of food in this manner that 
inclines me strongly to deprecate this mode of treatment, 
but I believe that it must sometimes be an exceedingly pain- 
ful operation. The sensation of something going the wrong 
way is familiar to us all, and it appears to me that pouring 
soup into the pharynx of a screaming and violently resisting 
patient is very apt to induce spasm of the glottis, or even 
cause the passage of some of the fluid into the lungs. I do 
not think that an exhausted patient could safely be submitted 
to such treatment." Another equally strong objection is 
urged by Dr. Tuke against this plan. " It involves the 
medical attendant in a sort of personal contest with his pa- 
tient, which must engender feelings of hostility most detri- 
mental to the exercise of moral influence. The medical 
attendant, living on terms of intimacy with his patients, 
should never descend to the position of a rough nurse. 
Feeding with a tube secundum artem is a painless surgical 
operation, which, if rapidly and skilfully done, will not give 
rise to the same feelings of degradation as I should imagine 



. _ ~- ~~o 
' funnel' feeding must occasion." 



Dr. Tuke has a great dread of the ordinary stomach-pump 



220 ACUTE MELANCHOLIA. 

tube, and prefers a small tube introduced into the stomach 
through the nose, if the patient will not open the mouth. 
" The instruments I use for injecting food into the stomach 
are oesophageal tubes about seventeen inches in length, made 
of elastic gum like an ordinary catheter, and of various 
diameters from the size of No. 3 to a No. 6 urethral catheter. 
One of these, if the patient will open his mouth, I pass down 
into the pharynx. If there is resistance, and the mouth is 
obstinately closed, I send the tube best adapted to the size 
of the nostril, without any stylet, but well oiled, along the 
floor of the nasal passage, and so into the cavity of the 
stomach." 

Various objections may be urged against this method, 
some of which Dr. Tuke admits and comments on. First, 
the catheter strikes against the cervical vertebrae, and there 
remains fixed : to obviate this difficulty various ingenious 
but complicated contrivances have been invented by the 
French, with which I will not now trouble you. " The 
remedy," says Dr. Tuke, " is simple. Let the instrument be 
previously bent so as to give it a tendency to turn down- 
wards; and, at the moment it approaches the posterior nares, 
let the head of the patient be thrown back, so as to diminish 
the sharpness of the angle it must describe. It is obvious 
that the operation should not be performed when the patient 
is in the supine position. 

" The next problem, that of avoiding the entrance of the 
larynx or the opening of the fauces, is solved by bringing 
the patient's head forwards and downwards, which will send 
the point of the tube against the posterior wall of the pharynx; 
but to a practiced manipulator this will not be necessary, 
and this part of the operation will be as easily performed as 
the tour de main with which a good surgeon sends the sound 
below the arch of the pubes into the bladder. The tube 
having thus far proceeded comes within the grasp of the 



ACUTE MELANCHOLIA. 221 

constrictor muscles, and now glides down the oesophagus 
almost without aid from the operator. 

"The next objection is the likelihood of the catheter 
entering the larynx, and the danger of the lungs thus re- 
ceiving the fluid intended for the stomach. This danger is 
common to tubes introduced either through the mouth or 
the nostril ; perhaps in the latter case the smallness of the 
tube may render the accident more probable. A simple rule 
will prevent this mischance producing any serious result. 
The operator must never attach his injecting apparatus to 
the catheter, before at least fourteen inches of the tube have 
been passed. If no violence has been used this will suffici- 
ently indicate that its point has entered the cavity of the 
stomach." 

I confess I think this argument fallacious. A tube might 
pass fourteen inches down the trachea, bronchus, and bron- 
chial ramifications, if we reckon these inches from the exte- 
rior of the nose ; and it is not easy to bend the head of a 
resisting patient backwards and forwards at our pleasure. 
It is also a disadvantage not to be able to feed a patient in 
the supine position. 

I have never seen any plan of feeding violent and refrac- 
tory patients which equalled that of Dr. Henry Ste- 

J r . . By the 

vens, late Medical Superintendent of St. Luke's Hos- stomach- 
pital. Having had considerable experience of this 
method, I will here describe it, because by it many of the 
objections usually urged against the stomach-pump are re- 
moved. 

Where a patient can be fed without extraordinary diffi- 
culty or exhaustion by Dr. Williams's method, I adopt it, 
and the sight of the stomach-pump apparatus laid out on a 
table at hand often produces a moral effect, and facilitates 
the operation, which is conducted by attendants in my pres- 
ence. If they cannot easily succeed, I use the stomach-pump 
after the following fashion : 



222 ACUTE MELANCHOLIA. 

In the first place, the patient is to be rendered incapable 
of sudden movements. Dr. Tuke says. " I have known one 
of the most expert surgeons in London pierce the thoracic 
aorta in consequence of the accidental movement of a patient 
while the tube of an ordinary stomach-pump was being 
passed down the oesophagus." Recollect that no grasping 
on the part of a number of attendants can hold a very 
powerful patient motionless, because they are not all the 
time acting together. The patient is to be placed in a 
wooden arm-chair, and his body, arms, and legs, are to be 
swathed in sheets drawn through the arms and legs of the 
chair so as to render him immovable. By this means all 
sudden movements and consequent accidents are prevented ; 
he cannot struggle, therefore there is no exhaustion, and 
bruising is prevented far more effectually than by Dr. Wil- 
liams's method. When the patient is thus fastened, half of 
Dr. Tuke's objections disappear. If the teeth were firmly 
closed, they were slowly and gradually opened by Dr. Ste- 
vens by a silver-plated wedge, which expanded by means of 
a screw ; thus without the slightest violence or chance of 
breaking a tooth, the teeth were separated sufficiently to 
insert the hard-wood gag, which was held by an attendant 
standing behind the patient. All chance of passing a tube 
into the glottis is obviated by using one of a size that will 
not enter it. Nothing is gained by using a very small tube; 
as we do not use the smallest-sized catheter to pass along an 
unstructured urethra, so we need not use a very fine tube to 
pass down the oesophagus, through which a coiner bolts his 
bad half-crowns with perfect impunity. The tube, then, 
should be at least of a size that will not enter the larynx; it 
must be flexible to the end, and must not have the stiff 
wooden extremity which generally terminates the tubes in 
the ordinary stornach-pump cases. Passing it through the 
hole in the gag, we direct it, not straight at the vertebrae, 
but to the right, having previously oiled it. No force what- 



ACUTE MELANCHOLIA. 223 

ever is to be used. In all probability the patient will hold 
it with his tongue, preventing its descent; we are not to 
force it, but simply hold it steadily; in a few seconds he is 
obliged to take breath, he relaxes his hold, and the tube 
slides within the action of the muscles by which it is swal- 
lowed, and so passes into the stomach. No haste is to be 
used in pushing it down or drawing it back. We then affix 
our injecting apparatus, which may be an ordinary brass 
pump or an India-rubber bottle. If the tube is not too small, 
the food need not be mere liquid drink, but may consist of a 
mess of finely-pounded meat and beef-tea thickened with 
potato or flour: it is important that there be an adequate 
quantity of farinaceous material. Such things as brandy, 
wine, eggs, and medicines may be added at discretion, and 
the medicines may be mixed with the food in or out of the 
sight of the patient, according as we think fit. Frequently, 
when he finds that we can administer all we wish him to 
take, he gives in, and takes his food. The preparations for 
feeding often produce the same effect; but I have found that 
patients do not experience any great pain or inconvenience 
from this method, and sometimes will refuse their food merely 
to give trouble. Such persons often dislike being fed by the 
spoon method far more than by the stomach-pump, as it is a 
longer process. One patient would eat all the rest of his 
meals if I would give him his breakfast with the stomach- 
pump; otherwise he would take nothing all day. This he 
continued for a month. Another gentleman who had had 
considerable experience of feeding in various ways, fell to 
discussing the subject with the attendants one day after I 
had fed him, and stoutly maintained that the stomach-pump, 
used as described, was the least unpleasant of any. Only ex- 
cessive violence can lead to such accidents as piercing the 
aorta. Even teeth can be got open without breaking, by tact 
and patience; and all danger of going the wrong way is at an 
end if the tube be of the proper size. Doubtless, some will 



224 ACUTE MELANCHOLIA. 

talk about mechanical restraint, and so forth: to these I would 
say, compare a patient struggling for fifteen to thirty minutes 
in the hands of three or four attendants, with one fastened 
with sheets in a chair for five minutes. Let both be seen 
before judgment is passed. 

It may occasionally happen that we are obliged to feed by 
force a patient who is not suffering from acute melancholia, 
but from some other variety of insanity — one who refuses food 
from sheer opposition, or because he thinks it poisoned. In 
such cases one or two operations generally work a cure ; but 
in acute melancholia we feed because the patient's life is 
jeopardized by want of food; and, in spite of our feeding, 
such a one may sink, for this acutely melancholy state is 
often only the last stage of a melancholy which has been 
gradually reducing the strength of the individual for months, 
and which for want of vigorous treatment in the early stages 
has gone on to a point when cure is impossible. Neverthe- 
less, we must not let a patient die of starvation, and as a long 
and exhausting struggle is not to be thought of, we must feed 
with the stomach-pump twice a day, or oftener. 

Chloral will bring sleep to these patients as to others, and 
we may give it in full doses at night, and in less doses in the 
morning, to allay the restless panic and frenzied agitation. 
The sufferer may after a small dose sleep half an hour or an 
hour, and then be quiet for some time, allowing himself to be 
fed with less resistance. In this way his strength may be 
husbanded and supported. And, besides chloral, morphia is 
valuable here, and no mode of administration is so service- 
able as the subcutaneous injections, for the patients 
will no more take medicine than food, and in the 
struggle to give it by the mouth much may be wasted, and we 
may not know exactly how much has been taken. Chloral, 
too, though it cannot be administered subcutaneously, may 
be given by the rectum. Never give pills ; patients will 
hold them in their mouths till your back is turned, and then 



ACUTE MELANCHOLIA. 225 

spit them out; you can never be certain that they are or are 
not swallowed. The morphia may be mixed with the food, 
but this is not nearly so satisfactory a method as the sub- 
cutaneous injection. Other medicines are not worth the 
struggle of getting them down. In so great debility, such 
drugs as bromide of potassium, tartar emetic, hydrocyanic 
acid, and digitalis, are, in my judgment, out of the question. 
The. warm- bath may promote sleep, and great warmth of 
rooms and clothing will be necessary. Such persons are not 
to be allowed to lie on the floor of an ordinary room all 
night, which they are very prone to do. There is a tendency 
in all to fatal pneumonia and gangrene of lung, and rather 
than run any risk of exposure, I would employ mechanical 
restraint, and fasten them in bed. Suicide is their one end 
and aim ; and, at the suggestion of the Commissioners in 
Lunacy themselves, I have employed mechanical restraint at 
night for such reasons as I have stated. 

In addition to the ordinary warm bath, the hot-air or Turk- 
ish bath may be tried in these cases of acute melancholia, if 
opportunity enables us to do so. I myself have not been 
able to apply this mode of treatment to any except those 
who could be sent out of the asylum ; but in some of our 
larger asylums it is systematically adopted, with proper 
rooms for carrying it out. 

The prognosis in this extreme form is, as I have already 
-said, unfavorable. It occurs chiefly in persons de- 

. Prognosis. 

bilitated by age, disease, or childbirth. And the 
obstinate refusal of food, and the struggles with which its 
administration is attended, add greatly to the danger of the 
disorder and to the difficulty of dealing with it. TliLs form 
of melancholia is rapid compared with the other. Very 
rarely can we give sufficient food, if the refusal is persistent. 
Hence many of these patients gradually sink. If the dis- 
order becomes chronic, and the bodily health improves, 
recovery may take place as in other forms of melancholia. 

15 



226 ACUTE PRIMARY DEMENTIA. 

Our power of prognosis will, of course, be greatly aided in 
these acute cases by the thermometer and the sphygmograph. 
The chances of life or death will be indicated with tolerable 
certainty by the temperature and the character of the pulse. 
But I need not say that it is difficult in the extreme to take 
observations of such a kind in the case of patients who resist 
all that is done to them.. Our fingers must be our guides, 
and by them we may learn the heightened temperature, and 
rapid pulse which are of such evil omen in acute melancholia 
and acute delirium. 

After speaking of these melancholy patients, I may fitly 
Acute primary describe a class which has been by some confounded 
dementia. w ith them. The form of disorder has received va- 
rious names, and has been brought under one or other of the 
varieties of insanity according to the views of different 
writers. It was described by Esquirol, and called by him 
" acute dementia," and this name is more often applied to it 
than any other. Pinel confounded it with a kind of idiocy, 
and named it " stupidite." M. Baillarger pronounced it to 
be a variety of melancholia, and > owing to the torpor and 
inactivity of the patients, called it " melancolie avec stupeur ;" 
and this name is still given to it by many — wrongly, how- 
ever, for melancolie avec stupeur is a very different disorder. 
Dr. Monro has proposed to apply to it the term " catalep- 
toid " insanity, and this word not inaptly expresses the lost 
automatic condition so often witnessed in those suffering from 
it. They are not, however, lost in woe, like those buried in 
profound melancholia, in melancolie avec stupeur. Rather are 
they lost in vacuity ; they look utterly idiotic and silly, like 
the chronic demented people seen in asylums and workhouses. 
Hence the name "acute dementia," " acute"" being used in 
contradistinction to chronic, meaning a curable disorder last- 
ing comparatively a short time. The term has been objected 
to, because it is said that we cannot call such a passive dis- 
order " acute," and because the minds of such patients are 



ACUTE PRIMARY DEMENTIA. 227 

not really demented. However, I will try to describe to you 
the disease, to which you may affix what name you like, pro- 
vided you clearly understand the symptoms. Dementia it is 
while it lasts, and perhaps we can give it no better name 
than " primary dementia," thus marking it off from the sec- 
ondary chronic dementia which follows other forms of insan- 
ity or organic disease of the brain. The patients are all 
young, from fifteen to twenty-five years of age. When we 
hear of a man or woman of fifty being thus affected, we may 
presume that the malady is melancolie avec stujpeur, or some- 
thing of the kind. It is not primary dementia. A young 
man, then, or a young woman, after some shock or fright, 
some appalling sight or intelligence, is frightened 

t , . SymptoniB. 

"out of his senses. He is horror-stricken, para- 
lyzed in mind, not merely deranged, not depressed or excited, 
but deprived of feeling and intellect ; his movements, if there 
be any, are automatic, but frequently he is motionless, stand- 
ing or sitting, staring at vacancy for hours and days. As I 
have said, this may come on suddenly after a fright, or it 
may be developed more gradually after some slight cause,, so 
slight that it has been unnoticed or forgotten by the friends.. 
In the case of one young man, it was a fall from a scaffold 
without injury beyond the frig] it and shake. Such are always 
persons of weak nerves, boys and girls who have outgrown 
their strength, and whose nervous condition is still further 
weakened by delicate bodily health. They do not converse; 
their answers are those of an idiot or demented patient. 
More frequently they give no reply. They are not always 
motionless ; often they are in incessant motion. One girl 
used to snap her jaws together for days at a time, and then 
changed to wagging her head from side to side. This action 
was truly automatic, for no effort of will could have kept up 
muscular motion for so long a time. They do not stop when 
spoken to, but if we give them a shake, they may perchance 
direct their attention to us for a moment, and then begin 



223 ACUTE PRIMARY DEMENTIA. 

again. They do not always remain the same. After "being 
for hours in a complete cataleptic or trance-like state, so as 
to make those about think they are in a fit or comatose, they 
will commence to laugh, chatter, or grimace in a silly and 
•idiotic fashion. There is apparently a complete mental 
blank, and sometimes after recovery we find that nothing is 
recollected. Sometimes they recollect all that has passed, 
though at the time they had no power or control over their 
actions. They may, however, resist violently when fed, 
dressed, or moved, resisting like the chronic demented with- 
out any reason, except that their quiet or automatic action is 
interfered with. 

The physical condition is peculiar. The circulation is so 
feeble that in the hottest weather hands and feet are blue 
with cold. In winter they are covered with chilblains, and 
there is great difficulty in keeping these from becoming sore. 
The heart's action and pulse are proportionately weak. 
Such patients do not lose flesh as those in acute mania or 
melancholia, but are flabby and pale. They do not eat, but 
can generally be fed without difficulty. They are wet and 
dirty, or do not pass water unless at long intervals, neither 
will the bowels of some act without enemata. Sleep may 
be irregular, but it is seldom absent, and frequently the 
amount is normal. 

You will have to distinguish this form of insanity from 
Diagnosis and 'melancholia cum stupore, and from chronic dementia. 
prognosis. Now, the patients affected with melancholia cum 
stwpore are seldom young. They have been melancholy from 
the commencement of the attack, are suicidal, rapidly ema- 
ciate, refuse food obstinately, and sleep little. In all of 
which they differ from those whose malady is primary de- 
mentia. The latter in the beginning are maniacal rather 
than melancholic, and rarely suicidal ; and when they get 
better, and can tell us something about themselves, we see 
that depression is not the leading characteristic of their 



ACUTE PRIMARY DEMENTIA. 229 

state, but that it is mainly extreme weakness of mind, con- 
sequent for the most part upon mental shock, or bodily de- 
bility, or both combined. How can we distinguish it from 
chronic dementia ? In other words, how can we say whether 
the patient will recover or not ? I confess that this is not 
easy. I have seen patients of whom I had hopes who have 
remained permanently in a demented condition. Everything 
will depend on the history. The appearance of the sufferer 
may be identical in primary and secondary dementia. You 
are shown a young man or a girl in a state of fatuous im- 
becility, grinning idiotically, lost, and dirty. Nothing can 
appear less promising. But if you are told that this condi- 
tion came on almost suddenly, especially if it followed a 
mental fright or shock, which seems to have been the origin 
of it, and if yon observe the physical symptoms I have men- 
tioned, indicating great weakness of the system and circula- 
tion, you may pronounce hopefully as to the result. But if 
the patient has gradually and imperceptibly drifted into this 
imbecile condition without assigned cause, then you may set 
it down that the cause is hereditary taint in the first place, 
and masturbation in the second, and that though improve- 
ment may take place, recovery is impossible. 

What is the treatment of these patients, and where is it 
to be carried out?i\J^do not think an asylum abso- 

Till Treatment. 

lutely necessary. In many the mental shock they 
have undergone would be intensified by such removal. If 
they are passive and tractable, they may be treated in a 
family, or even at home. And as they improve, change of 
scene will be of infinite service^ They require nutrition 
and stimulation — nutrition by means of abundance of food, 
and stimulation by wine and stout, and also such a stimulant 
as a shower-bath. In these cases especially, I believe shower- 
baths to be useful, a short sharp shower, and then plenty of 
friction to restore and promote the circulation. Above all, 
they require warmth : warmth which to us would be exces- 



230 ACUTE PRIMARY DEMENTIA. 

sive heat will not do more than warm them, and yon will 
find that many of them will continue in the same state 
through the winter, and wake up and recover when the hot 
summer comes. Tonics we may give, especially steel and 
small stimulating doses of morphia. Menstruation is sure 
to be absent, but we need not direct any special efforts 
towards it. As the general strength returns, it comes again, 
and meddling in this direction does more harm than good. 
We shall soon see, when a patient is subjected to treatment 
of this kind, whether there is an awakening of attention, 
and a return of mental strength. If there be, if we are 
conscious of an improvement, we need not despair, even if 
it be slow. 

I said in my last lecture that patients attacked with pri- 
mary dementia might be ranged at one end of the scale of 
the insane, for here we see the minimum of cerebral action 
and metamorphosis, the negative side of mind disorder, 
manifested in silly idiotic vacuity rather than in depression, 
excitement, or delusions. The bodily phenomena corre- 
spond : the circulation is lowered, the surface is cold, there 
is but little change going on, there is no waste, nothing but 
automatic movements or torpid inactivity. In my next 
lecture I shall present to you certain patients who are the 
very reverse of all this, whose insanity is shown in furious 
delirium, with incessant violence and entire sleeplessness, 
with so great waste and exhaustion that life may come to 
an end in a few days, or if recovery take place, the sufferer 
may be found to have lost flesh to a great extent, even in a 
very short period. This form I shall term acute delirious 
mania, and this may be fitly placed at the other end of the 
scale. 



LECTURE XI. 

Acute Delirious Mania — Diagnosis of Transitory Mania — How to Arrest 
it — Treatment of Prolonged Acute Delirium — Food — Nursing — Medi- 
cines — Baths — Purgatives — Prognosis — Diagnosis. 

Instead of a patient feeling something wrong for weeks or 
months, or the same thing being noticed for as long Acute 
a period by those around him, very acute symptoms delirium - 
of mania may arise in a few days or even hours. The pre- 
monitory stage of an attack of acute delirium, or acute 
mania, may be extremely brief; in fact, a patient may awake 
out of sleep, and at once become delirious. The more sudden 
the invasion, the shorter will be the duration of the attack 
in the majority of instances, but to all such rules there are 
many exceptions. Sudden outbursts of delirious mania fre- 
quently have their origin in a mental cause, as the death of 
a friend, a suddenly announced misfortune, a violent quarrel, 
a disappointment or cross in love. Any such circumstance 
occurring to a person of weak nerve, hysterical, and by 
nature predisposed to mental disturbance, may bring about 
very acute delirium in a few hours. 

The same thing may proceed from a cause clearly physical. 
It may arise in the course or during the decline of acute 
disease, as pneumonia, measles, or fever. It may come on 
in a patient who is phthisical, or has acute rheumatism, or 
who has undergone too great fatigue, as a very long walk. 
It may succeed a paroxysm of epilepsy, or take the place of 
one. It may come on quite suddenly after childbirth, expo- 
sure to the sun, or indulgence in drink. 



232 ACUTE DELIRIOUS MANIA. 

Now, we cannot say in every case whether an acute de- 
May be lirium will last a few hours or days, or whether it will 
transient. run ^ e ordinary course of an attack of delirious 
mania, and require special care and treatment for weeks or 
months. But it is all-important that we should arrive at 
some conclusion before we move a patient to an asylum. The 
prognosis in such a case is of the greatest consequence, and 
at the same time extremely difficult. 

Some information may be derived, first, from a considera- 
tion of the character and constitution and past history of the 
individual ; secondly, from the cause of the attack ; thirdly, 
from the symptoms observed. 

Some patients there are whose organization is so unstable, 
who are so prone to violent disturbance of the nervous system, 
that attacks of delirium may in them supervene upon an 
occurrence comparatively trifling. It is reasonable to hope 
that such an attack will be transient. If the individual has 
been hitherto unknown to us, we must discover, so far as is 
possible, what his or her temperament and character ordi- 
narily are ; above all, whether there have been previous 
attacks of a similar nature, and whether they were of long or 
short duration. If the attack has been gradually developing 
during a week or longer, without any assignable cause, it is 
not likely that it will suddenly terminate. Observation of 
the patient will teach us something. If amidst the paroxysms 
of delirium there are intervals of calm, during which the pa- 
tient is rational, we hope that the attack will be brief; also 
if there are intervals of sleep. If there is no sleep for three 
or four days, except perhaps short snatches of half an hour, 
and if during the whole of this time the patient is becoming 
more and more maniacal and delirious, we conclude that an 
attack of acute mania has begun, through which he must be 
nursed, and which cannot now be arrested. We shall also 
be aided by observing the physical condition, noticing if there 
be symptoms of hysterical delirium, copious voiding of pale 



ACUTE DELIRIOUS MANIA. 233 

urine, indications of amatory feeling, pretended inability to 
speak, and other peculiarities denoting that even with appa- 
rently very violent delirium there is complete appreciation of 
all that is going on, and considerable exercise of volition in 
what is done. We constantly see cases which would be de- 
scribed by one as mere hysterics, by another as an attack of 
transitory delirious mania, and it is not easy to distinguish 
one from the other. 

What can we do to bring this condition to a conclusion ? 
It is necessary above all things to determine whether Howto 
the attack is going to be transient or prolonged before arrestlt - 
we remove the sufferer to an asylum, for the terror inspired 
by the removal would be very likely to convert one of the 
short attacks into a prolonged and obstinate mania; and if 
this were not the result, we should yet regret that we had 
placed a person in such a position for an insanity of so passing 
a character. Three or four days will set our doubts at rest, 
and then if the patient cannot be managed out of an asylum, 
to an asylum he must go. 

There are doubtless many patients who, if treated at home 
by friends and among friends, would rapidly recover, but who, 
when removed by force and placed among strangers, experi- 
ence a much more prolonged and severe attack. Yet such a 
step is often unavoidable. Suppose that a man becomes 
acutely maniacal in a seaside lodging: he cannot remain there 
three or four days till it is decided whether his disorder will 
suddenly terminate or not. He would require to be violently 
restrained, most probably by strangers, and he might not be 
safe in such an abode : removal becomes imperative, and we 
can advise nothing else under the circumstances. But, as I 
have said, when it is possible to wait and watch the case, let 
it be done. 

In the year 1869, I saw two most acute cases of delirious 
mania commencing in seaside lodgings. One was that of a 
gentleman aged thirty-one. He had had two previous attacks 



234 ACUTE DELIRIOUS MANIA. 

of mania within a twelvemonth. The first occurred in his 
own home. He was then full of fancies, which at times he 
recognized as delusions ; but once or twice he woke in the 
night in a paroxysm of terror, accompanied by great excite- 
ment, and violently attacked a friend and his brother, who 
were his nurses. This great excitement, however, passed off 
in an hour or two, and in a few days he was well. The second 
attack merely consisted of a number of the old delusions, 
which reappeared and disappeared again after change of scene 
and visits to friends. The third, as I have said, commenced 
at the seaside, after premonitory symptoms of sleeplessness 
and religious delusions of about a week's duration. He was 
inclined to run away ; his wife called in the police to her as- 
sistance, and he then broke out into violent delirium, was 
brought to London, and at once taken to an asylum, where I 
found him. He perpetually heard voices, talked of religious 
subjects, refused food, had paroxysms of violent fury, in 
which he attacked all about him, and intervals of rationality, 
in which he washed and bathed himself, and ate a hearty 
meal. He was treated with drachm doses of bromide of 
potassium. The first night he slept three hours, the second 
two, and the third four, and after that he slept naturally, 
and by the end of a week he was perfectly himself, and re- 
sumed his usual work and occupation in the asylum, where 
he stayed a fortnight longer. In six months he had another 
attack, which also began at the seaside. In this he was even 
more violent and desperately suicidal. He was now treated 
with chloral, which quickly subdued the sleeplessness and 
delirium. He has not, however, fully recovered, and it is a 
question whether he ever will. There is insanity in his 
family. He is one of the many examples met with of patients 
who hear voices. Whether these are chronic or acute cases, 
the prognosis is in all unfavorable. Here, though the patient 
seemed perfectly to recover, the symptoms returned every six 



ACUTE DELIRIOUS MANIA. 235 

months ; and, as might be expected, they now threaten chronic 
insanity, and probably an early termination of life. 

The other was a young lady of twenty-one, in whose family, 
as in that of the gentleman, insanity existed. She was not 
removed from the sea for a fortnight, her violence making it 
impossible. She experienced a most acute attack of delirious 
mania, recollecting nothing afterwards of what occurred. 
The contrast in these two cases was evident to one watching 
them. In the girl's the attack had been coming on for 
months : there was no sleep beyond the briefest snatches for 
a week, and there were no intervals of quiet or rationality. 
Her tongue, her odor, indicated from the first the serious 
nature of the disorder ; but of this prolonged mania I shall 
speak hereafter. It ran a course of violence lasting nearly a 
month, and then came great weakness and prostration, and 
gradual but perfect recovery. 

What treatment are we to adopt when this acute mania 
first breaks out ? We cannot say for certain whether we can 
cut it short ; but we hope to do so. 

We have at this time a remedy in the hydrate of chloral, 
of more value than anything that ever was given be- 
fore its discovery. Opium in anything like a sthenic 
case generally made matters worse. Bromide of potassium 
was of greater value, but it did not surely produce sleep. 
Hyoscyamus, digitalis, cannabis Indica, were uncertain reme- 
dies, on which we could not depend. But many of these 
cases are cut short and cured, like delirium tremens, if we 
can procure one long and sound sleep, and I believe that 
chloral will generally be found to cause sleep of a longer or 
shorter duration. If the patient is strong and the excitement 
waxing vehement, give a drachm. 1 have seen a very violent 
maniac sent to sleep by such a dose, and wake clear of every- 
thing like delirium, though he still had delusions. Chloral 
does not cure insanity : it is given nightly to the chronic in- 
sane ; they sleep, but are not cured. In them the disorder of 



Chloral. 



236 ACUTE DELIRIOUS MANIA. 

the brain is fixed and incurable ; but in the early stages of 
acute insanity, after one sleep the sufferer often wakes restored, 
and this sleep we can bring about by chloral in a way we 
never could formerly. 

By the side of this drug it seems scarcely worth while to 
mention the modes of attaining sleep which were once 
adopted. But I may say that I have seen the violent mania 
of an approaching attack subside more than once after a brisk 
purgative. Whatever be the action of this, whether we are 
to call it, in the language of a bygone age, a derivative, a re- 
vulsive, or a counter-irritant, its effect is often marked and 
evident, and the patient recovers. 

There is another remedy sometimes tried, viz., packing in 
a wet sheet. A sheet dipped in water, hot or cold, 

Wet sheet. 

according to circumstances, and wrung out, is laid 
on a mattress protected by a Mackintosh sheet and a blanket, 
and the patient, placed on this, is wrapped so as to include 
arms, legs, and in fact, the whole body with the exception 
of the head. The blanket is then tucked over him, and other 
blankets laid over all. Dr. Lockhart Robertson, the great 
advocate of the cold-water wet sheet, recommends that when 
the patient has been in the sheet for an hour or an hour and 
a half, he should be taken out, rubbed thoroughly with a 
dripping cold sheet, and replaced in another wet sheet and 
blankets, and that after each change of sheet two pails of cold 
water should be poured over him. He says that in some 
cases of recent mania he has pursued this system throughout 
the day, or three or four times in the day, or less frequently. 
We must be careful, however, how we employ it, for like the 
prolonged warm bath, the prolonged shower bath, and other 
desperate methods of cutting short mania, it is not unattended 
with risk. I believe, however, that merely packing up in a 
sheet wrung out of hot water gives us without danger the 
chief advantages of the system. It is a powerful sudorific, 
and promotes sleep by reducing to the minimum the power 



ACUTE DELIRIOUS MANIA. 237 

of motion. There can be no question that when the latter is 
taken away, patients will often fall asleep. This is one of 
the chief arguments used by the advocates of restraint, and I 
have no doubt that in their experience they saw this effect 
produced. Now, the wet sheet, as a medical appliance, has 
advantages over the strait-waistcoat. It will, I presume, be 
denied by those who use the wet sheet that its chief good 
arises from its being a form of mechanical restraint ; but that 
it is the latter, for good or evil, there needs no argument to 
prove. 

If a patient sleeps three hours at a time within twenty-four 
of the commencement of the delirious outbreak, and awakes 
calmer, and sleeps again in the next twenty-four hours — and 
if his attacks of violence are paroxysmal, with comparatively 
lucid intervals, his mind not getting more and more lost and 
confused, — we may hope that the malady will soon terminate 
in long and healthy sleep, after which he may awake com- 
paratively well, like one awakening from the sleep which term- 
inates delirium tremens. But if the snatches of sleep Prolonged 
become shorter, the patient waking in a paroxysm of attack - 
rage and terror — if the delusions grow wilder and more sense- 
less, and he takes less notice of those about him, violently 
resisting all that is done for him, — we may make up our 
minds that he has entered upon an attack of acute delirious 
mania which cannot be cut short, but through which he must 
be nursed for days or weeks. 

I need not take up your time by a lengthy description of 
the disorder, for in truth it is hardly possible to mistake it 
for any other. The name " acute delirious mania" sufficiently 
describes it. I shall have a few words to say on the diagnosis 
and distinction between it and some other forms of delirium; 
but however alike these may be for a time, the history and 
progress sufficiently distinguish them from this form of in- 
sanity. 

I have already spoken of the premonitory symptoms of 



238 ACUTE DELIRIOUS MANIA. 

acute delirium. The oncoming of a transitory attack is 
usually more rapid than that of one more prolonged. In the 
latter case the change may have been noticed for a long or 
a short time, from a week to three or four months, presenting 
the ordinary features of mental derangement, such as in one 
may terminate in melancholia, in another in mania, while in 
a third it may be fixed in a quiet monomania. Generally 
speaking, after a brief period of alteration, some casual oppo- 
sition, heat of weather, or accidental circumstance, lights up 
the violent stage, while gradually-lessening sleep precipitates 
the attack. When any such symptoms are apparent, it is 
right to bear in mind that the night is the time when the 
acute stage is most likely to commence. This is important, 
because a patient is apt to be less guarded at this hour than 
at any other. Wives are alone with their husbands, out of 
reach, it may be, of all male assistance ; or a man may be in 
a room at the top of the house by himself, possibly locked in. 
Friends are afraid to place attendants with a person in this 
condition, for fear of irritating him, and will often keep them 
out of sight till mischief is done. The most violent stage is 
not usually at the commencement of the malady, though a 
patient may be violent for a short time, paroxysmally. As 
I have said, this may terminate in sleep, or he will go on get- 
ting worse and worse, more full of delusions, more uncon- 
scious, and utterly sleepless, till all hope of speedy termina- 
tion is past. 

We have thus arrived at a stage when the patient, man 
Disposal of or woman, cannot any longer be treated in an ordi- 
patient. na ry bedroom, or nursed by relatives and ordinary 
nurses. Whether he must be removed to an asylum will 
depend on his means, on his house and the inmates of it, or 
of adjoining houses. An asylum is not absolutely necessary 
to his recovery. He does not require amusement, or occu- 
pation, or grounds and garden. He is going to be actually 
ill for a fortnight or longer, and to be confined to one room 



ACUTE DELIRIOUS MANIA. 239 

for that time. Upon the room much will depend, but little 
on its locality. He cannot be nursed by near relatives; it 
is therefore essential that very skilful people shall be about 
him, in whom full confidence can be placed. 

The room, in or out of an asylum, should be large enough 
to be airy and cool; the windows must be out of reach, or 
protected, yet capable of being opened, and also of being 
darkened, and the darkened state must be kept up during 
the height of the attack. The patient will not lie quietly 
on a bedstead, and attempts to compel him to do so will end 
in many bruises, if not in broken ribs. So the bed must be 
made up on the floor, a considerable surface of which may 
be covered with mattresses. Few patients will allow any 
clothes to remain on — they will strip them off and tear them 
in pieces. They must not, however, go naked ; a strong 
suit, consisting of jacket and trousers, or petticoat, fastened 
together in one piece, and laced up the back, may be securely 
fastened on them, and underneath it may be placed the requi- 
site body linen; or a patient may have a blanket fastened 
round his neck and shoulders so as to form a kind of poncho. 
If this be well fastened round his arms, they will not be 
very available for mischief, and yet there will be no irksome 
restraint. He can also be easily held without the infliction 
of a single bruise. The scantiest furniture should be left in 
the room — utensils will be little needed, for such patients 
are almost invariably wet and dirty — and for drinking, a 
horn-cup is better than glass or china. Near relatives must 
keep out of sight, for their presence will not be tranquilliz- 
ing, but the reverse, to the bewildered mind ; yet the occa- 
sional glimpse of some one he knows — an old servant, friend, 
or doctor — may reassure and make him think that the strange 
faces he sees are not those of enemies, persecutors, or fiends. 
Many are aware of what is going on, far more than is sus- 
pected; though they make no sign, they take in all that 
passes, and no better advice can be given to those in charge 



240 ACUTE DELIRIOUS MANIA. 

than to be careful that they say nothing in presence of a 
patient that he is not to hear. If we in his presence order 
medicine to be mixed with food, we may run the risk of its 
being refused, even if he is apparently in the most uncon- 
scious delirium. 

The old writers used to describe in glowing terms the vio- 
lence and ravings of these maniacs; and in the days of chains, 
manacles, stone floors, and straw, doubtless their appearance 
was terrible. But they are not the really dangerous lunatics, 
and their violence is for the most part temporary and par- 
oxysmal, though they may pass hours and even days, in 
singing, shouting, and perpetual motion. There is not much 
to say about the mental symptoms : commonly the speech is 
an incoherent jumble of sentences, or the constant repetition 
of a word or phrase, beginning in a low tone and rising in a 
crescendo till the room rings with their piercing cry. They 
can in many cases be hardly said to have any delusions — 
at least these are not to be made out in their confused jar- 
gon, but the prevailing feeling is markedly shown in their 
expression, tone, and gestures. This may be fear, in which 
they will call on some familiar name for assistance, will 
scream " fire !" or " murder !" and in every way indicate the 
terror they are in. Or they may be filled with religious 
dread, and refuse food, remain incessantly on their knees, 
and see the horrors of hell before them. This is, in my 
opinion, a very unfavorable symptom, and this variety is 
closely akin to, if not identical with, the worst form of acute 
melancholia. They may be furiously angry, and attack those 
in charge, applying opprobrious names in accordance with 
their ideas ; or they may be gay and hilarious, laughing and 
shouting with glee and mischief. 

I believe our prognosis may be materially affected by a 
careful consideration of the emotional state. On the one 
hand we find the panic-stricken, on the other the hilarious. 
When I see a patient laugh and frolic, however noisy and 



ACUTE DELIRIOUS MANIA. 241 

outrageous his or her delirium, I augur favorably concerning 
the termination. I believe that the gayety indicates a reserve 
of force which does not exist in the other ; we may often ob- 
serve during the disorder that the spirits of the patient will 
rise or fall as he loses strength or regains it from food, or a 
period of quiet or sleep. 

What are the bodily symptoms ? Entire absence of sleep 
for days together. One young lady, in the heat of 
the summer of 1868, only slept one hour in eight 
days. She then slept five hours, and began to mend. The 
time at which sleep first comes varies much, and the time 
also varies during which patients can go without sleep with- 
out fatal exhaustion occurring. Women can go much longer 
than men, and unless debilitated by some such cause as par- 
turition, generally battle through an attack of mania : we 
have not the same need for alarm as in the case of the other 
sex. Young women from twenty to thirty years of age are 
often the subjects of this disorder, and almost always get 
well — at any rate in the first attack. Patients will exist a 
long time without becoming exhausted by want of sleep if 
they are well kept up with food, and are kept from wearing 
themselves out with incessant motion and fatiguing exertion. 

The tongue of a patient in this condition is generally furred 
and coated with a thick sticky layer of dead epithe- 

, . . n Tongue. 

hum, and in proportion to the heat, ievenshness, 
and shouting of the patient, this will become brown and dry, 
and the teeth will be covered with sordes. As exhaustion, 
and that condition we call typhoid, come on, all this will of 
course become worse. In some cases, however, particularly 
in women, the tongue keeps wonderfully clean and moist, 
even if the attack be a long one, and this is a good sign. 
Taken in conjunction with the pulse, the state of the tongue 
is a valuable indication. A very quick pulse is a bad symp- 
tom. During the paroxysms of violent struggling 
and incessant motion the pulse may become very 

16 



242 ACUTE DELIRIOUS MANIA. 

rapid, and then fall again in an interval of comparative quiet 
to a normal rate. Such a condition of things is hopeful. If, 
however, the acceleration continues, and, with the temper- 
ature, is kept up at a high rate, then the case is likely to do 
badly. Taken generally, the pulse of patients who recover 
is in frequency below that which we should expect when we 
see their great muscular efforts and profuse perspiration. The 
latter is very offensive, and in females we often perceive an 
overpowering odor of sexual excitement. 

The water is generally scanty and high-colored, and may 
be contrasted with that of patients who are suffering from 
transitory or hysterical attacks, when it is often copious and 
pale. The bowels rarely act without medicine, and very 
powerful aperients may be required : the stools are usually 
dark and very offensive. Both urine and faeces are passed 
about the room or bed-clothes, and the latter may be daubed 
about the patient's person or surroundings. 

The appetite is very capricious, but as a rule these patients 
do not refuse their food. At the commencement of the attack 
they may labor under the delusion that it is poisoned, but as 
the state of excitement increases they seem to forget this, and 
will take a large amount, if it is given to them judiciously. 

What is the treatment and what the prognosis of these 
cases of acute delirious mania? Our object is to 

Treatment. . 

nurse a patient through the violent and sleepless 
stage, and to support his strength, so that he shall not die 
of exhaustion during it. It is exhaustion that kills : we do 
not find by post-mortem examination any lesion of the brain 
or other organ sufficient to cause death. It would seem as 
if the disorder is one which has a natural tendency to sub- 
side after a longer or shorter time, if only he can hold out 
till this time arrives ; and so we see that the young and the 
strong pull through, while those debilitated from any cause 
succumb. Everything, then, depends on the amount of sup.- 
port we can introduce by dint of feeding, and the extent to 



ACUTE DELIRIOUS MANIA. 243 

which we can prevent a patient from exhausting himself by 
violent struggles and want of sleep. When he is quiet — 
when he does not take much out of himself — our anxiety is 
comparatively small, even if sleep is long in coming. Now, 
with regard to food : skilful attendants will coax a patient 
into taking a large quantity, and we can hardly give too 
much. Messes of minced meat with potato and greens diluted 
with beef-tea, bread and milk, rum and milk, arrowroot, and 
so on, may be got down. Never give mere liquids so long 
as you can get down solids. As the malady progresses the 
tongue and mouth may become so dry and foul that nothing 
but liquids can be swallowed ; but reserving our beef-tea and 
brandy, let us give plenty of solid food while we can. I 
never knew a patient in this state vomit his food, or 
suffer from diarrhoea. He will require plenty of drink 
also, especially if the weather be hot; and we may give cool- 
ing mixtures, as lemonade, in any quantity. If the patient 
is young and vigorous he will want no stimulants — that is, 
brandy and wine — at any rate at the commencement of the 
attack. These, like opium, will only increase the excitement. 
We may, however, give bottled ale or stout, a glass at a 
time. The waste of tissue in this disorder is enormous, and 
patients rapidly lose flesh, and we learn hence the necessity 
for an increased quantity of food. It is quite possible by pa- 
tience and tact to get down a liberal allowance: without actual 
forcing, they will permit themselves to be fed, and a female 
nurse will often be of great service in this respect among 
male patients. In the same way a female will often take 
food from the doctor's hands rather than from the nurse's. 

Good attendants will not only feed a patient — they will 
also nurse him. A man or woman in this condition is to be 
looked upon essentially as a sick person, and not as a mere 
violent and noisy lunatic to be allowed to run about, or to 
be shut in a padded room and occasionally looked at and 
fed. Such a patient should not be allowed to be on his legs 



244 ACUTE DELIRIOUS MANIA. 

the whole of his time till he falls on the floor exhausted. At 
times he can be made to lie quiet enough by the side 
or in the lap of an attendant, especially if the latter 
fans his face or applies cold cloths to his head, for his vio- 
lence is, as I have said, paroxysmal, with frequent remis- 
sions, and he can either be allowed to walk about at his 
quiet times, being held on his back during a paroxysm till 
this subsides, or he can be allowed during the violent stage 
to go at large, being made to rest during the intermediate 
period. In this we must be guided by his strength, the 
degree to which he exhausts himself by his fury, and by the 
staff of attendants we have at hand. A man kept in the 
recumbent posture is far more likely to drop off to sleep than 
one who is perpetually pacing the room. 

There remain for consideration the various methods by 
which we are to procure or promote sleep. For a sleep of 
some hours' duration will be the turning-point of the illness, 
and this we look for anxiously till it arrives. Probably, 
nowadays, chloral will be the remedy first thought of, and 
none is more likely to succeed. Before its discovery those 
who had most experience were disposed to lay aside all drugs, 
as doing, upon the whole, more harm than good, and to trust 
rather to baths and such appliances to bring about sleep. 
But chloral has come to our aid, and by full doses repeated, 
I have hopes that we may procure sufficient sleep at 
any rate to save life, even if the disease is not cut short 
thereby. I have never seen a drachm dose given without 
being followed by some sleep, and that is more than I can 
say of any of the drugs formerly advocated for this terrible 
malady. It may occur to some that we ought to try opium 
or its preparations. I have said something of this already, 
and have only to add that in prolonged delirious mania I 
believe opium never does good, and may do great harm. 
opium not We shall see the effects of narcotic poisoning if it be 
to be given, p^he^ DU t none that are beneficial. This applies 



ACUTE DELIRIOUS MANIA. 245 

equally to opium given by the mouth and by subcutaneous 
injection. The latter, as it is more certain and effectual in 
producing good results, is also more deadly when it acts as a 
narcotic poison. After the administration of a dose of mor- 
phia by the subcutaneous method, the patient will not im- 
probably at once fall asleep, and we congratulate ourselves 
that our long-wished-for object is attained. But after half 
an hour or so the sleep suddenly terminates, and the mania 
and excitement are worse than before. Here you may pos- 
sibly think that had the dose been larger, instead of half an 
hour's sleep, you would have obtained one of longer duration, 
and you may administer more, but with a like result. Large 
doses of morphia not merely fail to procure refreshing sleep : 
they poison the patient, and produce, if not the symptoms 
of actual narcotic poisoning, at any rate that typhoid con- 
dition which indicates prostration and approaching collapse. 
I believe there is no drug, the use of which more often be- 
comes abuse, than that of opium in the treatment of insanity. 
Among the ancients the disorder was treated invariably by 
hellebore ; by our fathers by bleeding and tartar emetic ; 
now, till lately, by opium. Do not be led away by the fatal 
facility with which you can administer it by subcutaneous 
injection. Inject it in the case of a melancholic patient, if 
you like, but here, in this furious delirium, you must abstain 
from the administration of opium in all its forms. 

We may, however, promote the access of sleep by other 
means. And, first, I must speak of baths, which are largely 
used here, and still more abroad, as sedatives in cases 
of excited mania. The baths recommended for this 
purpose are always, so far as I know, hot : even mustard is 
to be added, according to some, to promote the determination 
of blood to the surface. This is the rationale of the treat- 
ment : cold is to be applied to the head by cloths and ice- 
bags while the patient is in the bath, and so the blood is to 
be "derived" thence. 



246 ACUTE DELIRIOUS MANIA. 

The French employ these baths for very long periods. M. 
Brierre de Boismont recommends that a patient should be 
kept in one for ten, fifteen, or eighteen hours ; but there must 
be considerable risk in so doing, and I should be sorry to 
recommend it. Unless the bath can be given effectually, it 
had better not be attempted. Merely holding a man in hot 
water for a few minutes, kicking and plunging, is not likely 
to quiet his mania, or to lower his circulation down to sleep- 
ing-point. To be of any use, it should be given for half an 
hour at least, with cold to the head. It should not be too 
hot : one at 90° or 92° is more likely to be cooling than one 
at 98°, and is less likely to cause syncope. After such a bath 
a patient may go to sleep. I have never seen a cold bath 
given ; but I should like to see the effect of placing a patient 
in a tepid bath, and allowing him to remain there till the 
water cooled. I cannot help thinking that a great general 
cooling of the body would thereby be produced without any 
shock, and that by the skin much would be absorbed to allay 
the fever and thirst, and replace what is lost by the profuse 
perspiration. 

Shower-baths are wholly inadmissible here ; to produce a 
sedative effect they would require to be given for a consider- 
able length of time, and would be productive of very great 
danger. 

Concerning purgatives : if we see the patient at the com- 
mencement of the outbreak, we may give a brisk purgative 
with the hope of arresting it. Later we cannot arrest it by 
any means, and we do not wish to lower his strength 

Purgatives. ^ . . n 

by strong purgation. If it is necessary to interfere 
at all, we may give a few grains of calomel, because they are 
easy to administer, or a dose of castor oil, if we can get it 
down. The latter is perhaps more likely to act than any- 
thing else. We must beware of giving pill after pill, or dose 
after dose, because those taken previously have not acted ; 



ACUTE DELIKTOUS MANIA. 247 

for when the stage of reaction sets in, we may have violent 
action from their combined effects. 

Are we to bleed in this acute delirium ? A few years ago 
such patients were invariably and largely bled. Nowadays 
general bleeding in insanity is in this country entirely abol- 
ished. Local bleeding by leeches or cupping is to some ex- 
tent advocated and practiced, but of it I myself, having had 
no experience, can say nothing. There would be considerable 
difficulty in accomplishing it in most cases, and, in my 
opinion, it is not needed, for the only patients whom we 
should think of bleeding are the young and strong, and these 
almost invariably get well without it. The cases which suc- 
cumb to this disorder are those in which we should never 
think of abstracting blood. 

I have lately seen two girls to whose nape and spine blis- 
tering fluid had been applied. They passed many days in 
furious mania, and the sore places became dreadful wounds, 
depriving them of both sleep and rest, and, being followed 
by a crop of boils and pustules, retarded greatly their re- 
covery. I advise you to abstain altogether from blisters, and 
from everything which is likely to make a wound and to ex- 
cite suppuration, which is very prone to occur. Surgery 
under such circumstances is most difficult and unsatisfactory, 
and nothing should be done which is likely to call for surgi- 
cal interference or dressing. 

What is the prognosis ? In my own experience I have 
not found this a hopeless disease, though it is most 
formidable to treat. A well-known French authority, 
M. Marce, says that of these patients (del ire aigue) scarcely 
one in three or four recovers. I should say about one in 
three or four dies. I have found that young unmarried 
women, who frequently are the subjects of this disorder, and 
of hereditary insanity, generally recover; that the women 
who die are those weakened by childbearing or phthisis, or 
advanced in age ; that young men seldom die in the first at- 



Prognosis. 



248 ACUTE DELIRIOUS MANIA. 

tack ; that the men who die are those who have had repeated 
attacks, or are advanced in life, or weakened by such causes as 
phthisis, hemorrhage, or want of food. The disease, as a 
rule, occurs in the young, in patients between the ages of 
twenty and thirty. Modifications and varieties of it occurring 
in older persons are more akin to delirium tremens, or the 
transitory delirium of wasting and acute diseases. But this 
is not the true acute delirious mania of which I have just 
been speaking. 

The terminations are almost invariably recovery or death. 
If the delirium continues, and no sleep comes, the patient 
becomes weaker and weaker, the pulse more uniformly rapid, 
the mind more unconscious, not recognizing at all those in 
the room. The tongue is brown and dry, profuse sweating 
bedews the forehead, emaciation rapidly advances ; and when 
at last the sufferer becomes quiet, and lies on his bed without 
attempting to rise, instead of sleep we see coma and collapse 
supervening, and an exhaustion which rest does not remove. 
When coma sets in, it generally increases quickly; there are 
evident signs of serous effusion taking place within the cra- 
nium, and death soon follows. When the termination is in 
recovery, sleep is the first harbinger of it. Sleep comes, per- 
haps at first for two or three hours, but on awaking there is 
manifestly an improvement, evidence that this short sleep has 
had an effect. Then probably in no long time we get other 
sleeps, then a long one of six or seven hours, and then we 
may consider the crisis past ; and although there may be a 
very maniacal condition lasting perhaps for weeks, there will 
not be again the same absence of sleep, the same danger to 
life. The time occupied in recovery varies indefinitely. A 
patient may be perfectly well in a month from the commence- 
ment of a very acute attack with a long period of sleepless 
delirium. On the other hand, he may remain for weeks or 
months in a condition of nervous prostration and dementia, 
and then slowly recover. We find here and there a patient 



ACUTE DELIRIOUS MANIA. 249 

who never recovers, but remains permanently in a state of 
chronic mania or chronic dementia; but such instances are, 
I think, rare, and even those whose families are saturated 
with insanity, and who have an attack of acute delirium 
without other apparent cause, get well in a most satisfactory 
manner, at any rate in the first attack. There is one variety, 
however, which is the most formidable of all to treat, and 
which does not in general recover, but terminates fatally. 
This is a class of patients who, with all the violence, sleep- 
lessness, and delirium of genuine acute delirious mania, ob- 
stinately persist in refusing food, as obstinately as others 
afflicted with acute melancholia. They do not make the 
passive resistance of the melancholy ; they waste in their 
violent condition far faster, and require much food, yet none 
can be got down, except by force. As the utmost we can 
give' in this way is inadequate to their need, and as it always 
implies a struggle, whatever method of feeding we adopt, 
they generally sink rapidly and die. Among them we do 
not find the gay and lively ; but, on the contrary, they are 
filled for the most part with religious and other horrors. In 
fact, the malady merits the name of acute melancholia rather 
than acute mania. 

I need say but a very few words concerning the diagnosis 
of this disorder. Those most likely to be confounded with 
it are various forms of delirium. 1. I have known a 

. Diagnosis. 

gentleman sent to an asylum as suffering from acute 
mania who was raving drunk. He had been drinking for 
days, but he had no delirium tremens ; he was simply mad 
drunk, and so soon as he had slept off the liquor he was well, 
and could not be detained. Here a grave mistake was made, 
and it should be a rule with you never to sign a certificate 
for a patient w T ho is at the time under the influence of drink. 
2. A man may be in a condition of delirium tremens. If it can 
be helped, we do not send such patients to asylums, knowing 
that the attack will be brief. You will observe the tremor, 



250 ACUTE DELIRIOUS MANIA. 

the busy restless fumbling, and the terrified aspect which is 
not generally seen in maniacs. Even without a history you 
can hardly mistake the two, and delirium tremens occurs in 
men advanced in years much more frequently than acute 
mania. The delusions and hallucinations also are very dif- 
ferent. Maniacs seldom see snakes or rats, which so often 
torment the drunkards. 3. The delirious fever patient is a 
very different being to the maniac. There is no difficulty in 
keeping him in bed, though he be noisy and incoherent. His 
aspect is quite different, and of course his malady was not at 
its commencement mental. 4. Still less need I mention pa- 
tients suffering from acute disease of the brain, meningitis, 
&c. We have other symptoms to guide us, — rigors, squint- 
ing, vomiting, coma, convulsions, a totally different pulse, 
and complaints of excessive pain, which last is rarely com- 
plained of in mania. 



Acute mania. 



LECTURE XII. 

Acute Mania — Symptoms — Treatment — Medicines — Prognosis — Termi- 
nations — Treatment of various Insane Patients — The Insanity of 
Puberty — Masturbators — Puerperal Insanity — Insanity after a Blow 
— Coup cle Soleil — Syphilis — Rheumatism — Epilepsy — Phthisis — 
Monomania. 

The next form of insanity of which I have to speak to you 
is very different. It is called by many acute mania, 
as is also the last described. You may, if you like, 
call it u acute mania without delirium," as the other is 
"acute mania with delirium;" but it is a very different dis- 
order. Whereas the former is a disease running a rapid 
course to recovery or death in a week or two, this may last 
for months without much danger to life. The patients are 
little less violent or noisy, but they know what they are 
about — their violence has in it far more of design ; and sleep 
is not absent as in acute delirium. This mania may come 
on like the latter, almost suddenly, or with premonitory 
symptoms of some duration. In two cases lately treated, 
the disorder was stated to have lasted in one for three days, 
in the other for a month. These persons are mischievous in 
an extreme degree, wet and dirty, not from uncon- 

• i . i i i • s*i i • Symptoms. 

sciousness, but to give trouble, abusive, filthy m 
language and habits — presenting, in short, all the worst 
features of the insane. Having their wits about them, they 
know very well how they can annoy, and are extremely 
ingenious in provoking the attendants, and complaining of 
them afterwards. They may be, and often are, full of de- 
lusions, or their insanity may consist chiefly of outrageous 



252 ACUTE MANIA. 

conduct and language. They are perfectly unmanageable 
out of an asylum : acute delirium can be treated in a suitable 
room in any house, and the sufferer may recover, as so many 
do who are said to have had "brain fever;" but I do not 
think that many of these noisy maniacs could be treated 
with a view to recovery in a private house. To keep them 
there at all would probably entail very rough handling. 

What is the mental, and what the bodily state of these 
people ? They may talk quite coherently for some time, or 
for a few minutes only, rambling off in incoherent nonsense, 
or may commence singing or shouting, or will abuse us vio- 
lently, with full consciousness of who we are. Their mental 
state varies from a power of keeping up a conversation and 
concealing the insanity, so as almost to baffle us in signing 
a certificate, to a degree of wild incoherence which might be 
taken for delirium ; and their acts and deeds vary also, but 
at the height of the disorder they almost all destroy clothes, 
furniture, sheets, and windows. They are abusive and in- 
clined to fight, and rack their vocabulary for opprobrious 
and obscene terms. Often they are given to self-abuse, which 
they will practice with open and shameless audacity; at 
other times they expose their person to cause annoyance and 
disgust. 

The bodily health is generally tolerably good, and suffers 
less than we might expect from the severity of the disorder. 
They seldom die of it unless their health is much broken at 
the commencement. It comes on, however, occasionally in 
persons whose strength has been much impaired, and then 
if they do not recover shortly, they may gradually wear 
themselves out and sink. This was the case with an officer 
who had suffered severely from wounds and exposure in 
India. He never recovered, but sank after being many 
months in confinement. He was in an extreme state of 
emaciation when it began. 

Such patients are not all young, like the majority of those 



ACUTE MANIA. 253 

who suffer from acute delirium. Many are men of forty 
years and upwards, yet, as I say, few die. They generally 
eat heartily, nay, voraciously, if allowed, and although in 
time they get thinner, do not waste rapidly. Sleep is de- 
ficient. They pass a good night, sleeping six or seven hours, 
and then go for days with perhaps only one or two hours' 
sleep, making night hideous with shouting, laughing, and 
singing, and disturbing all within hearing. They seem to 
acquire an ability for doing without sleep, which may last 
for a couple of months. The tongue is not particularly foul 
or coated, and may after a short time become quite clean, 
while the bowels will act without much trouble. In short, 
the bodily health is not a matter of grave anxiety : our chief 
object is to calm their unquiet mind. Now, although medi- 
cinal means are not to be neglected, much may be 

rn -i i , , , -, " , . Treatment. 

effected by moral treatment, moral control, and dis- 
cipline. Not by stripes and chains, as was recommended 
by Cullen and others, but by a system of moral rewards and 
punishments, their violence is to be checked, and a wish for 
a return to civilized life to be roused. Here no rule can be 
laid down which is applicable to every case, or even to a 
majority; but your own common sense will probably suggest 
to you how a patient is to be encouraged, how repressed. 
There are many things which he will delight in, and look 
for, as tobacco, snuff, or wine ; various indulgences, as walks 
or games. These may be granted for good behavior, and 
withheld for bad. These noisy maniacs are very like chil- 
dren in many respects ; their turbulent behavior, and mis- 
chief committed often for mere bravado, their dirtiness and 
untidiness, and the utter senselessness and folly of their pro- 
ceedings, remind one constantly of wilful and naughty chil- 
dren, and they are often capable of being influenced by 
analogous processes. We must devise something which shall 
help them to restrain themselves — something which they will 
attain to if they behave properly — something which they 



254 ACUTE MANIA. 

will lose if they continue in violence and mischief. I once 
had under my care a most outrageous patient, the terror of 
attendants and the pest of the asylum, who committed great 
damage and destruction to property. He went on in this 
way for four months. I then placed two men with him con- 
stantly, so as to give him no opportunity for mischief, and 
entirely stopped his tobacco, of which he was greatly en- 
amoured. This had a marvellous effect, and in a month's 
time he was discharged, and continued well for some years. 
Some patients who tear their clothes to pieces will abstain 
if they have a new suit given to them, or a suit of a different 
kind or color ; others will require the constant surveillance 
of attendants till the habit is broken through. For, like 
pulling out the hair, or picking the face or fingers, tearing- 
up is often a habit and employment for the hands, which 
must be kept from it, and, if possible, employed in something 
else. Nothing is of so much service in these cases as pro- 
longed exercise in the open air. Let the patient be in the 
open air as much as possible, and let him be well walked 
between two attendants; his exuberance of spirits will be 
checked, and he will sleep all the better. As the last men- 
tioned patients were to be considered sick, and kept in one 
room and nursed, so these are to be looked upon as in fair 
bodily health, are not to be kept in bed or in one room, 
but, on the contrary, are to have as much exercise as we 
can give them, unless it be contraindicated by some diseased 
condition. 

Are medicines of use here ? In many cases we shall find 
them of great use, but may probably have to make 

Medicines. ° 7 t p 

trial of more than one before we cure our patient. 
Chloral will procure sleep with certainty if the dose be large 
enough. Some have said that this sleep is useless ; that, 
procured by this means, it does not shorten the attack. Ex- 
perience of the drug is as yet limited ; but I cannot but think 
that six or seven hours' sleep even of this kind, repeated 



ACUTE MANIA. 255 

night after night, must be in the end beneficial, and must 
tend to shorten, not to prolong, the disorder. I lately saw 
a patient suffering from acute mania with consciousness, who 
had had a similar attack several years previously, in which 
he had passed some six days and nights without sleep. He 
now slept every night for three or four hours, after fifty 
grains of chloral. By day he was noisy, violent, and dirty, 
exhibiting the disease by well-marked and characteristic 
symptoms. Yet the acute stage, on the latter occasion, lasted 
no longer than on the former. Sometimes in the less sthenic 
cases opium is of service, and procures sleep at night; we 
cannot always say beforehand whether its effect will be bene- 
ficial, but here we can try it : it is not a matter on which 
hangs life or death. If it is of no use, we may give digitalis, 
bromide of potassium, extract of henbane, cannabis Indica, 
or a combination of them, e. g., the bromide and cannabis. 
We may administer the morphia by subcutaneous injection, 
if there is a difficulty in getting medicines swallowed. Com- 
paring this mode of administration with the ordinary plan, 
I have found but little difference in the effect produced by 
the drug ; but a less quantity of the salt is required if it be 
subcutaneously injected. Two other drugs I may mention : one, 
which was formerly used almost universally in the treatment 
of insanity, is the potassio-tartrate of antimony — antimonium 
turtaratum, as it is now called; the other is hydrocyanic acid. 
The former has been largely given for years in many asy- 
lums, and frequently acts beneficially, quieting the patients 
I have described, and also chronic maniacs. Here it pro- 
duces no nausea in small doses (3 or h gr.), neither does it 
cause any aversion to food. One young lady to whom I gave 
it took food better than before. It might be given subcuta- 
neously, but of this plan I have no experience. Its small 
bulk, solubility, and the absence of taste and color, enable it 
to be mixed with facility in any kind of drink. 

The other, hydrocyanic acid, is, like digitalis, an old 



256 ACUTE MANIA. 

remedy revived. Dr. Burrows, in his " Commentaries," tells 
us that Dr. Balmanno, of the Glasgow Asylum, used to give 
from 15 to 30 drops of a- diluted solution of it, preparatory 
to giving narcotics, but that he himself had found no good 
results. In papers in the " Medical Times and Gazette," 
March, 1863, Dr. Kenneth McLeod, of the Durham Lunatic 
Asylum, strongly recommends its use as a calmant in cases 
of acute mania and melancholia, in doses of from rr^ij to ttjjvj, 
to be given by the mouth or subcutaneously, and repeated 
every quarter of an hour till an effect is produced. I think 
this quite worth a trial in these cases; but if the dose, say of 
TTgy, which Dr. McLeod recommends, is to be repeated every 
quarter of an hour, it must be done under your own super- 
vision. 

What is the prognosis of the disorder? As in most forms 
of acute insanity, it is favorable, if there be no com- 

Prognosis. , , 

plications of other disease. Our opinion as to re- 
covery will be founded on the consideration of the following 
facts : 1. How long has the attack lasted? This, of course, 
is a matter of some importance, for if the disorder is becom- 
ing chronic, our hopes will be less ; but these patients often 
continue their violent conduct for a long time, and yet at last 
recover. I have known one recover after having been in an 
asylum nearly two years, and it was his fourth attack. 2. 
The character of the mania. If great noise and turbulent 
excitement are the predominant features, with no very 
marked delusions, or with delusions ever changing, and not 
fixed and immovable, we may have hope. If the delusions 
do not vary, if they have reference to the unseen and super- 
natural, above all, if the patient hears voices, the cure is very 
doubtful. 3. The age of the patients. Many of these are 
not very youthful, as I have said ; the younger they are, 
however, the more chance they have of recovering ; and, as 
a rule, I believe men recover more frequently from this form 
of insanity than women. 4. If the patient at the commence- 



MANIA. 257 

ment of the disorder is greatly debilitated, or if there is other 
disease, the violence and want of sleep still further reduce 
his strength, and interfere with the chance of recovery, v and 
if there be much difficulty in getting him to take food, his 
prospects are still more gloomy. And this brings me to 
another portion of my subject, viz., the terminations of the 
disorder. First, the patient may recover, and that T ermina- 
after a very considerable time. And it is not to be tions - 
forgotten, that if medicines and the moral control of one 
asylum and one set of attendants have failed, great good may 
be effected by removal to another, to entirely new hands and 
surroundings. It is often the only thing left for us to try; 
but no less often is it a remedy of marvellous effect. I shall 
have to recur to this again ; but I mention it here, as in these 
cases the good that is done is frequently very apparent. Sec- 
ondly, the patient may sink and die, gradually worn out by 
the disorder, or by intercurrent disease. Thirdly, he may 
lapse into a chronic condition of mania or dementia; or, 
what is more favorable, he may quiet down into melancholia. 
From this he may recover, or after a period of depression 
may again become excited and maniacal, his disorder becom- 
ing the fulie circulaire of the French. 

There are, however, many patients whose insanity cannot 
be called melancholy of any kind, neither is it acute delirium 
or acute mania. It is something short of the latter, and, in 
ordinary parlance, it is called mania. Depression is not a 
marked feature, except, perhaps, at the outset. There is at 
times angry excitement, complaints of being detained, of de- 
lusions not being listened to, and requests not being complied 
with. Such patients are capricious in temper, sometimes 
friendly, sometimes hostile, dangerous according to their de- 
lusions, seldom suicidal, prompt to escape, threatening ven- 
geance and an appeal to a jury. They require tact and 
patience, are not to be subjugated by intellects inferior to 

17 



258 MANIA. 

their own, and are as a class to be cured by moral rather 
than medicinal measures. 

We feel no anxiety about the life of these maniacs. When 
the disorder is recent, and the acute symptoms at their 
height, sleep may be defective, their eating may be irregular, 
and they may threaten to refuse food. But they seldom do; 
hunger asserts its claim, and they satisfy it. And a dose of 
chloral, repeated for a few nights, generally produces sound 
sleep. We may notice other bodily ailments requiring medi- 
cal attention, or a general debility, to be met by tonics and 
generous diet; but many have little the matter with the 
bodily health, and seclusion from home and the world, 
change of occupation and amusement, and regularity of life, 
work a cure with but little assistance from the Pharma- 
copoeia. Frequently they refuse to take medicines, and 
none being specially necessary, none are forced upon them. 
If you search the case-books of any large asylum, you will 
see that a not inconsiderable proportion of the patients re- 
covered are of this class. Probably they would be termed by 
certain writers cases of idiopathic mania, in persons who upon 
some moral or mental disquiet, or even without assignable 
cause, suddenly or gradually show signs of non-acute insanity, 
and when properly cared for, get well again without any 
very special treatment beyond seclusion and restraint. The 
majority of these inherit the disorder. They, too, are the 
people so often allowed to run loose, without care or treat- 
ment, till chance of cure is gone. The symptoms are not 
urgent, the patient is rational and well-conducted in many 
ways : it seems a shame to call him a madman, and deprive 
him of liberty, and so months and years are allowed to 
elapse, till the friends become tired of his vagaries or ex- 
penditure, and he is then brought to an asylum, where it is 
expected that he will immediately be cured, because they 
have always heard that it was the proper place for him. 
Possibly at the commencement the cure might have been 



TREATMENT OF VAKIOUS INSANE PATIENTS. 259 

effected ; but it is certain that chronic mania, or monomania, 
as it is often called, cannot be cured when it is of two or 
three years' standing. 

I am supposing that all these patients labor under delu- 
sions or hallucinations. When we speak of chronic mania 
this is implied. And the recent and curable mania which I 
am describing is equally characterized by these fancies. In 
a subsequent lecture I shall bring before your notice people 
whose insanity is not marked by delusions, but by insane 
acts and conduct. Now, however, you will bear in mind 
that in these patients delusions are a marked feature, and 
the prognosis will be determined in some degree by the char- 
acters and continuance of them. Of this subject I have 
already spoken, and have endeavored to point out how the 
prognosis is influenced by delusions or hallucinations of one 
kind or another. 

If we try to connect the symptoms with the pathological 
conditions mentioned in my third and fourth lec- 

J Treatment of 

tures, how are the treatment and chance of cure various insane 
affected thereby? There is an insanity of pubes- 
cence, of pregnancy, after childbirth, at the climacteric, an 
insanity connected with masturbation or sexual irritability, 
a sympathetic or reflex insanity, an insanity depending on 
alcohol. How does the diagnosis of one or other of these 
affect our prognosis or treatment? 

The insanity of pubescence is marked by violence, excite- 
ment, maniacal conduct, rarely by depression or Iusanityof 
melancholic features. Delusions there may be, and P ubcrt r- 
hallucinations, but not of a formidable or persistent nature. 
The majority of cases would be called by some "sthenic" 
rather than " asthenic." Sleep, though defective, is not 
altogether absent, and may be brought about by exercise in 
the open air, and by chloral, or bromide of potassium, rather 
than by opium. Stimulants are not needed, and produce 
excitement and a prolongation of the symptoms. In girls, 



260 TREATMENT OF VARIOUS INSANE PATIENTS. 

we shall find that the catamenial function is generally dis- 
ordered, the menses scanty or profuse. In the latter case, 
local treatment is preferable to anything given by the mouth, 
and pessaries, containing tannin or matico, may be applied 
per vaginam. In the former, iron and aloetic preparations 
are often of service. The majority of these patients get 
well, at any rate in the first attack ; but as they almost all 
inherit the malady — which inheritance is, in truth, the cause 
of it — its recurrence is to be looked for at some period or 
other of their lives. 

After this, I may fitly speak of the insanity of masturba- 
insanityof tion, reminding you that patients whose insanity 
masturbators. j g causec i ^y masturbation are generally by inherit- 
ance prone to mental disturbance. That masturbation by 
itself is not a frequent cause of insanity, is a fact of which 
all must be aware: were it so, in all our schools insanity 
would be an every-day occurrence. In some persons, already 
predisposed, it may light up the disorder, and may coexist 
with it in others without being the cause. The latter may, 
and do, get well, and when well may relinquish the habit. 
But the habitual masturbator, whose insanity has been grad- 
ually developing perhaps for years, is incurable. Thin and 
sickly-looking, he seems ever on the verge of consumption, 
and, though he may eat voraciously, his appearance is always 
a discredit to those who have to care for him. You have 
doubtless heard of various methods of preventing or curing 
this habit — of clitoridectomy, which is certainly inefficacious, 
the clitoris not being the only sensitive portion of the genital 
organs — of the application of ice to a female — of blistering 
the prepuce of a male — of the administration of antaphro- 
disiacs, of which bromide of potassium is supposed to be the 
most efficacious — and of various mechanical cages and con- 
trivances for preventing the contact of the patient's fingers. 
After considerable experience, I am sure that it is next to 
impossible to prevent it in a very determined person. Slight 



TREATMENT OF VARIOUS INSANE RATIENTS. 261 

confinement of the hands of a quiet or demented patient in 
what is called a pinafore or muffler, may suffice ; but many 
women will boast that they can effect their object by the 
friction of their thighs, or the application of the heel. And 
a man whose hands are confined may do the same by friction 
against the bedding. Blistering the prepuce can rarely be 
maintained for a sufficient time; and when the sore is healed, 
the man returns to his practice. I have certainly found 
bromide of potassium produce some effect; and one woman 
confessed that it took away the power of accomplishment. 
But bromide perseveringly given for weeks and months will 
make many patients wretchedly thin and weak, and it is by 
this effect that it appears to act. We are obliged to discon- 
tinue it, and with the strength the habit returns. Nothing 
but close personal watching will really stop it. A patient's 
clothes inay be so constructed that he cannot by day carry it 
on in the presence of others; and at night, some slight con- 
finement of the hands, and rigorous surveillance, may greatly 
check it. It will also be necessary to see that it is not prac- 
ticed at the closet, whither such patients frequently resort 
on pretence of a legitimate desire. In many instances, while 
a prospect of cure exists, it is worth while to exercise every 
precaution, and to try if a total suspension may not only 
eradicate the habit, but also restore the mind. An examina- 
tion of the linen will afford us information of the continuance 
or discontinuance of it in males: in females it is often diffi- 
cult to arrive at a just conclusion, for questions upon the 
subject are better avoided. We gain little information, for 
by all but the most hopeless it is sure to be denied. We are 
not to suppose that every patient suffering from acute insanity 
who may be detected in this is therefore incurable. I have 
known many recover, even after a considerable period, who 
were guilty of such acts. But of their insanity masturbation 
was not the cause, but only the concomitant, and when reason 
returned, this, like any other insane and dirty habit, was 



262 TREATMENT OF VARIOUS INSANE PATIENTS. 

abandoned. Yet I have heard a most unfavorable prognosis 
pronounced, which was founded solely on the fact that such 
acts were perpetrated. In acute delirium occurring in young 
women, we may find it in the large majority of cases: it ex- 
isted to an extreme degree in two lately under my care, yet- 
both recovered rapidly and perfectly. 

Turning to another form, viz., climacteric insanity, we see 
climacteric a number of patients whose malady and condition is 
insanity, truly asthenic, whose disorder is evidenced for the 
most part by deep depression, who are suffering, in short, 
from melancholia. The treatment I have sufficiently indi- 
cated in my ninth and tenth lectures. 

Puerperal mania is a disorder often described in works 
Puerperal upon midwifery, as well as in those upon mental dis- 
insanity. orders; but the term very inadequately describes 
the condition of the women who from this cause become in- 
sane; for they may show signs of aberration before child- 
birth, and both before and after it the symptoms may be 
those not of mania but of melancholia. Dr. T. Batty Tuke, 
in an examination of 155 cases admitted into the Royal Edin- 
burgh Asylum, tells us that 28 were of the insanity of preg- 
nancy, and that the symptoms in these are, as a rule, of the 
melancholic type, the suicidal tendency being very marked. 
"The prognosis in this form of disease is generally favorable; 
nineteen cases recovered within six months ; and of itself it 
is not fatal." My own experience confirms this. Such women 
are suicidal, refuse their food, and require to be treated in 
all respects like other melancholic patients. With care and 
good feeding they usually recover. The question will arise, 
ought labor to be induced prematurely? Looking at the favor- 
able results of cases which have gone their full time, I should 
say that, except for very special reasons, such a proceeding 
is not necessary. 

Dr. Batty Tuke examined the records of 73 cases of puer- 
peral insanity, in all save two of which, symptoms appeared 



TREATMENT OF VARIOUS INSANE PATIENTS. 263 

within one month of confinement. Where they commenced 
in the first sixteen days the form of insanity was acute mania ; 
later it was melancholia. 

Bearing out my own observations as to the general treat- 
ment of the two types, Dr. Tuke tells us that in the melan- 
cholic women the administration of large doses of morphia 
was attended with the very best results, while he feels certain 
that where mania has established itself, sedatives in large 
doses will not be found successful in the majority of cases. 
In the very commencement of puerperal insanity, I know that 
the greatest good has followed the administration of chloral, 
and that an impending attack has been cut short ; but at this 
critical period I should apprehend as much evil as good from 
a dose of morphia. As the period after childbirth is length- 
ened, the maniacal symptoms decrease, and those of melan- 
cholia become more prominent. Of 54 cases called by Dr. 
Tuke "insanity of lactation," 10 were examples of acute 
mania, 39 of melancholia, and 5 of dementia. " The acute 
mania, as a rule, in this form of insanity, is severe, but evan- 
escent ; it rarely lasts more than ten days or a fortnight, and 
is generally attended with hallucinations of the different 
senses, and delusions, as in puerperal mania, of mistaken 
identity. In almost all cases of insanity of lactation which 
have come under my notice during the last two years, exoph- 
thalmia and bruit de diable have been marked symptoms." 

I think these cases plainly indicate, what I have so strongly 
insisted on, that the mental symptoms depend on the gen- 
eral pathological strength and condition of the patient at the 
moment of the outbreak, and not upon the nature of the ex- 
citing cause. 

Of the remaining pathological varieties of insanity, some 
are incurable, and require little notice here. That which 
follows a blow on the head, and gradually and in- insanity after 
sidiously makes its appearance, is a form from ablow - 
which recovery rarely takes place. Treatment can do little, 



264 TREATMENT OF VARIOUS INSANE PATIENTS. 

for as a rule such patients are not subjected to treatment till 
the disorder is chronic. Many persons, however, who have 
received blows on the head, though not chronic lunatics, 
suffer from attacks of temporary insanity, if subjected to any 
exciting controversy or irritation, or if they partake even of 
a moderate amount of strong drink. Precautionary measures 
and advice may be of benefit, and may ward off more serious 
evil. We frequently meet with patients of this class who 
are in an incipient state of insanity — in what is termed moral 
insanity — and are very difficult to deal with legally till they 
arrive at a stage when hopes of cure are small. With this 
form another — viz., insanity following sunstroke — has been 
coupled by Dr. F. Skae.* It is, however, a mere conjecture to 
suppose that the pathological state produced by a blow is 
identical with that produced by coup de soleil. In this country 
insanity after we find but few examples of the latter. In my ex- 
coup de soieii. p er j ence the insanity does not come on gradually 
as in patients who have had a blow, but quickly develops, 
runs the course of acute mania with acute hypenemia of the 
brain, and terminates in death or recovery in a comparatively 
short time. I have seen many persons who went through 
such attacks in India, were invalided home, and arrived in 
England quite well. Some had subsequent attacks, the 
mania recurring as it might have done in any one who had 
suffered from an attack of acute insanity. The prognosis 
here is very much more favorable than in cases where the 
disorder follows a blow. It is worth while, however, to note 
that writers, and amongst them Drs. Bucknill and Robertson, 
have recorded the fact that a blow on the head has produced 
sanity in a patient previously of unsound mind. 

You will find in the majority of the cases of syphilitic 
syphmtic insanity that changes and degeneration have com- 
insanity. m enced in the bones, membranes, or brain, render- 

* Edinburgh Medical Journal, Feb., 1866. 



TREATMENT OF VARIOUS INSANE PATIENTS. 265 

ing the prognosis extremely unfavorable. Yet patients do 
recover. I lately saw a woman who had been under the care 
of a surgeon for syphilitic head symptoms, among others, 
ptosis of the left eyelid. She became violently maniacal, 
and was sent to an asylum, where she perfectly recovered in 
about four or five months. In these cases iodide of potassium 
is often of as great service as in other forms of syphilitic 
affection. 

If you have reason to suspect that an attack of insanity is 
connected with rheumatism or gout, and the patient Insanity with 
has already suffered from either of these maladies, rheumatism - 
you may direct your treatment with reference to them. 
There is not, I fear, any method by which we can compel the 
disorder to leave the brain and invade other organs, but it 
may be worth while, by counter-irritation, or by poultices 
and fomentations applied to parts formerly affected, to invite 
it to the feet, ankles, or knees. And such medicines as 
potash, iodide of potassium, or even colchicum, may be 
administered. It is to be noted that the cerebral symptoms 
may precede the articular inflammation. There may be vio- 
lent mental disturbance lasting some time, and subsiding 
quite suddenly, to be followed by swelling and pain in the 
limbs, varying from a slight affection of the great toe, up to 
genuine acute articular rheumatism. The transition may 
take place more than once, the rheumatic symptoms vanish- 
ing more or less completely as the cerebral return. The 
prognosis is, generally speaking, favorable ; recovery takes 
place after a time, but the patient is liable to a recurrence of 
the attack. Besides the gout there may be other predispos- 
ing causes of insanity: one gentleman, whose mania gener- 
ally terminated in gout, had had one or two epileptic fits. 
He died, however, of general decay, not insane nor epileptic. 

Though insanity is found in connection with acute rheu- 
matism, it is a variety differing from the delirium which I 



266 TREATMENT OF VARIOUS INSANE PATIENTS. 

spoke of as making its appearance towards the decline of acute 
. . disorders, as fevers, pneumonia, measles, and the 

Insanity in ' L J J 

like. This insanity, as it appears suddenly without 
premonitory warning, disappears for the most part as 
suddenly, one long sleep terminating the attack. Though 
its unlooked-for advent may cause the utmost consternation 
amongst the patient's friends, our prognosis need not be un- 
favorable, for most cases do well, and only require to be care- 
fully watched and guarded during the transient aberration ; 
opium has been found to agree with them, as it does with 
the asthenic generally, and I have no doubt that chloral also 
will bring sleep. Indeed, recovery takes place without any 
special treatment, if only plentiful nourishment is adminis- 
tered, for there can be no question that this condition is 
brought about by the debilitated state of the patient, and by 
the tendency to disturbance of the brain circulation, which 
probably all such persons possess by idiosyncrasy and inherit- 
ance. Instead of an acute delirium we sometimes find a 
melancholy or demented condition coming on as the sequel 
of one of the acute disorders, more formidable as regards the 
prognosis, though to the bystanders the symptoms may be 
less alarming. In the treatment of these forms of insanity, 
you will proceed on the plan laid down in the lectures on 
melancholy and acute dementia, remembering the need of 
food and warmth in both of these varieties, remembering that 
melancholy is curable, even after a very long period, and that 
from the most lost and apparently hopeless dementia patients 
will emerge and recover, if they receive the constant care, 
watching, and feeding, they so urgently require. 

Very violent is the mania which follows an epileptic 
Epileptic attack, or series of attacks, in certain cases, yet we 
insanity. m ay reasonably expect it to subside in a compara- 
tively short time, and measures for the treatment of the 
patient must be arranged in view of such a result. It sel- 



TREATMENT OF VARIOUS INSANE PATIENTS. 267 

dom happens that mania follows the first epileptic seizure. 
According to the frequency of them we may infer that the 
individual will be a long or a short time free from mental dis- 
order. If the attacks are infrequent, and it is possible to 
guard him at home during the maniacal period, we may do 
so, as in a few days he may be in a condition of sanity; but 
if the epileptic seizures are, or are becoming, frequent, and 
the maniacal state continues more or less throughout the 
intermediate time — if in his mania he is violent and danger- 
ous, and his means and surroundings do not admit of safe 
treatment at home — it will be proper to remove him to an 
asylum. These persons are often very dangerous, sudden, 
and furious in their acts, and haunted bv voices and other 
hallucinations. We must try and bring about sleep by 
chloral or bromide of potassium, and with each sleep the 
symptoms will be mitigated : occasionally, when we find 
mere delirium instead of mania with delusions and hallu- 
cinations, the whole may subside after one long sleep. 

Of mania in conjunction with phthisis little need be said 
specially. Where the symptoms rise to the height Ph thisicai 
of acute delirious mania, the tubercular complication insanit - v 
renders our prognosis unfavorable, and the sufferer will prob- 
ably sink. Where we find ordinary mania with excitement, 
and little sleep, but with no very exhausting violence or deep 
depression, we may entertain great hopes of a recovery, at 
any rate from the mental disturbance : there may be very 
little cough, or complaint of chest affection, and our atten- 
tion may be altogether drawn aside from the latter, if we 
have no previous history of haemoptysis or other lung symp- 
toms. Patients may gain flesh while in the insane state. 
When the latter has passed away, the lung disorder may 
again become prominent ; and some have thought that 
there is a kind of vicarious action between the two sets of 
symptoms. 

In addition to mania, certain authors describe a form of 



268 TREATMENT OF VARIOUS INSANE PATIENTS. 

insanity which they call monomania, but are not agreed as 
to the symptoms which the term denotes. Gries- 

Monomania. . . , 

mger, following Esquirol, who first introduced the 
word, would confine it to those patients whose mental dis- 
order is displayed in expansive delusions, in over-estimation 
of self. Dr. Bucknill says that it is seldom primary, and is, 
in the majority of cases, a transformation of melancholia, 
i, e., the self-feeling is one of depression, not of exaltation. 
Nothing, however, is to be gained by dividing patients into 
those affected by mania, in contradistinction to others whose 
disorder is monomania. Probably that which is most com- 
monly called monomania is chronic insanity, when the 
patient is removed from deep depression on the one hand, 
and gay or angry excitement on the other, and when the 
bodily health has assumed its ordinary level, and all patho- 
logical marks have by time been effaced. The distinction 
between mania and monomania is, for the most part, verbal. 
Formerly all insanity was called "melancholy;" nowadays 
it is often spoken of as mania, and if chronic as monomania. 
There is nothing pathological in such a nomenclature, and it 
only serves to draw us away from the due consideration of 
the pathology of the disease we have to consider and treat. 
We may retain such terms as acute delirious mania, acute 
melancholia, acute dementia, general paralysis, because they 
connote a certain set of pathological symptoms occurring in 
individuals of various ages, requiring special treatment, and 
capable of receiving a similar prognosis. We may, if we 
like, retain, besides, the general terms mania and melan- 
cholia; but beyond this we need not go: any further distinc- 
tions should be made, not according to mental peculiarities, 
but according to the pathological causes or conditions of the 
case. 



LECTURE XIII. 

General Paralysis of the Insane — Discover}' of the Disease — Three 
Stages — First Stage — Alteration — Second Stage — Alienation — 
Mental and Bodily Symptoms — Epileptiform Attacks — Terminations 
of Second Stage — Temporary Improvement and Apparent Recovery 
— Third Stage — Progressive Paralysis and Dementia — Sex and Age 
of Patients. 

I have now to lay before you the description of a terrible 
form of insanity, which is probably the most fatal disease that 
attacks man, destroying in a short period not only mind, but 
life itself — so fatal, that a well-authenticated case of recovery 
is, I believe, unknown — so common, that among 194 patients 
admitted during the year 1869 into the Devon Asylum, 43 
were affected by it. More, I think, has been written concern- 
ing this than about all other kinds of insanity; yet about the 
pathology and nature of the disease, there are still great 
doubt and controversy. It is best known by the name of 
General Paralysis of the Insane. 

To the French physicians unquestionably belongs the credit 
of having first recognized and described it as a spe- Discovery of 
cial form of insanity. The credit, however, must the disoase - 
be divided amongst several. Esquirol recognized the incur- 
ability of insanity complicated with paralysis, but he looked 
upon the latter as a complication, and did not consider the 
whole a distinct malady. In 1822,-Bayle, for the first time, 
noted that the mental disturbance and paralysis were syn- 
chronous, and attributed them to chronic inflammation of 
the arachnoid. In a complete description of the disease, 
which he divided into three periods, he calls it arachnitis 
chroiiique. M. Delaye, in 1824, thought that it was not al- 



270 GENERAL PARALYSIS OF THE INSANE. 

ways accompanied by insanity, and was a softening or atro- 
phy of the brain, with adhesions of the membranes. In 1 826, 
M. Calmeil gave a most complete account of it, and to him 
frequently is ascribed the merit of having been the discoverer. 
For many years he has paid great attention to the disease, 
and in his " Treatise on the Inflammatory Diseases of the 
Brain," published in 1859, he has given us his latest views 
of its nature, founded on a valuable series of cases. From 
that date, 1826, the disorder has been mentioned, at any rate, 
by all who have written on insanity, and many have devoted 
much labor to the investigation of the pathology thereof. 
Among the French, Bayle, Delaye, Calmeil, Georget, Par- 
chappe, Baillarger, J. Falret, Moreau of Tours, Brierre de 
Boismont; among the Germans, Duchek, Hoffmann, Joffe, 
L. Meyer, Erlenmeyer, Rokitansky, Wedl, Meschede, West- 
phal ; in England, Austin, Sankey, Lockhart Clarke, Wilks, 
Bucknill, and others, have contributed the result of their 
observations of the disease. 

There have been many names proposed for it. Some of 
the best are demence paralytique, folie paralytique, paralysie 
generale incomplete, paralysie generale progressive ; Geis- 
teskrankheit mit Paralyse, allgemeine progressive Gehirn- 
lahmung, paralytischer Blodsinn. In this country it has 
usually been called general paralysis, or general paralysis 
of the insane, or paralytic insanity. Lately, some have pro- 
posed to call it paresis, instead of paralysis. As by so doing 
we only substitute for the old name one equally vague and 
unscientific, it seems scarcely worth while to make the 
change. Various names have been given, based on the sup- 
posed pathology, some calling it a chronic meningitis, others 
an inflammation of the cortical structure — " periencephalite 
chronique diffuse" of Calmeil. It is thoroughly recognized 
by all alienists under the term general paralysis, and under 
that I shall speak of it here. 

This fatal malady destroys hundreds every year in our 



GENERAL PARALYSIS OF THE INSANE. 271 

asylums, chiefly men in the prime of life. Its symptoms and 
progress, and the mode in which you are to recognize it, I 
shall now endeavor to describe. General paralysis has been 
said to present three or four stages. Like every- 

, . l • i i i i i i_i Three stages. 

thing else, it has a beginning and an end, and there 
is, of course, an intermediate period of varying duration ; but 
frequently a patient advances with gradual but certain pro- 
gress from the beginning to the end, without our being able 
to fix the dates of any stages in the disorder. It may be 
convenient, however, to describe it at different periods, and 
for this purpose we may consider three : 

1st. The commencement, or period of incubation. 

2d. The acute maniacal period. 

3d. The period of chronic mania lapsing into dementia, 
with utter prostration both of mind and body. 

In the beginning, those who are familiar with the patient 
will notice in him an alteration. Like other lima- Fir8t stage> 
tics, he will arrest attention by his altered manner Alteration - 
and habits, before it is plain that he has become insane. 
I have already described to you the alteration that frequently 
takes place in a man who is drifting into melancholia or 
mania. We shall see a change preceding general paralysis 
similar in some respects, but having its own peculiarities. 
These are not very easy to describe or detect, and are not 
present in every case ; where we see them, they are valuable 
aids to diagnosis. 

Paralytics, like others, show an alteration by extravagant 
acts, often by an extravagant expenditure of money, by 
making presents to those they know and those they don't 
know. Now, in all they do there is a silliness betokening a 
greater want and defect of mind than is evinced by melan- 
cholic or maniacal patients. The same act will be done in 
two different ways. Maniacal and melancholic patients often 
show considerable vigor and power of intellect, albeit insane. 
They will reason and argue sharply, and defend their de- 



272 GENERAL PARALYSIS OF THE INSANE. 

lusions with much acumen. A general paralytic asserts his 
delusions, or commits his outrageous acts, but he does not 
argue keenly in defence of them. He does things which 
even a patient afflicted with what is termed moral insanity 
would not do ; exposes his person, often apparently half un- 
conscious of what he is about ; commits assaults in a foolish 
manner upon women, without regard to opportunity, place, 
or consequences. He is extremely restless, regardless of 
appointments, or the time of meals, bedtime, and the like; 
he comes and goes, scarcely noticing those about him, gives 
conflicting and absurd orders to his servants, and rages with 
passion if they are not executed on the instant. There is 
a want of plan and method in his madness, which may be 
contrasted with that of other patients, who in the early stage 
are far more suspicious and careful, if they are in the state 
analogous to this. One, and a most important symptom, is 
early to be observed, that is, forgetfulness. There is a want 
of memory. A man forgets what he has done, and what he 
has said, and this explains much that he does not do. He 
fails to keep appointments and regular hours. For the same 
reason he cannot sustain an argument. His business and 
occupation are neglected, and he forgets, too, the conse- 
quences of indecent acts, dishonesty, or debauchery. 

This loss of memory will be observable in many ways : 
especially is he likely to forget what he has done a day or 
two previously; and he will not only be forgetful, he will be 
careless, apathetic, and indifferent about that which formerly 
interested him, and when he takes up new schemes and pro- 
jects, his attention soon flags, and his interest vanishes. We 
see, in short, in his whole manner of life a weakening of 
mind, such as may be noticed at the commencement of senile 
dementia, but which, occurring in a fine and vigorous man of, 
it may be, thirty-five, too surely indicates the ruin even now 
commencing. 

In this stage patients are rarely seen by an alienist, but 



GENERAL PARALYSIS OF THE INSANE. 273 

the family adviser will probably be consulted concerning 
them. In it they may continue for a variable period, a few 
weeks, perhaps a month or two, never for a very lengthy 
time. The disease is essentially progressive, and the second 
stage follows rapidly upon the first in the majority of cases. 
The patient's mood in this early state is often dull and sulky, 
less frequently is he actually depressed and melancholic; but, 
careless of all save the idea of the moment, he wakes into 
violent rage when remonstrated with or thwarted. In one 
of these fits of passion his real state is often much more 
recognizable than when he is quiet and reserved. You will 
hear that he sleeps badly, that he eats and drinks irregularly, 
often voraciously, drinking to excess from inattention and 
forge tfulness of what he has taken. He spills his food on 
his dress, eating in careless haste, and is neglectful of his 
person and appearance, often dressing in incongruous garb. 

By degrees his dull and morose condition is converted into 
one of excitement. Something occurs which neces- second stage, 
sitates opposition or interference, and the mental Alienation - 
alteration becomes manifest insanity of a kind which requires 
immediate care and treatment. We now see the patient in 
a maniacal condition, marked by several peculiarities, to 
which I must call your earnest attention. Almost all, cer- 
tainly nineteen out of twenty, paralytic patients are full of 
ideas of their greatness, importance, and riches. Meutal 
They are self-satisfied in no ordinary degree, and s >' m i ,toms 
think themselves the most wonderful people that ever lived. 
Here and there we may find one depressed and melancholic, 
but his melancholia is different from ordinary melancholia, 
as the man with grandiose notions diners from him who 
suffers from ordinary mania with delusions of greatness or 
wealth. There is in the latter a certain probability and 
reasonableness, even in his wildest fancies ; but the ideas of 
the paralytic are altogether absurd, impossible, and unintel- 
ligible, evincing his loss of mind as well as aberration. An 

18 



274 GENERAL PARALYSIS OF THE INSANE. 

ordinary maniac may think himself a duke, or may purchase 
a carriage and horses which he cannot pay for; but a para- 
lytic will tell us that he is a duke, a marquis, a king, and an 
emperor all at once, that he is going to marry the Queen and 
all the princesses, that he has a hundred million of horses, 
and is going to pull down all London to-day and rebuild it 
to-morrow. Ordinary maniacs do not talk in this wild and 
absurd fashion. They invent wonderful machines which will 
make their fortunes, and discover the method of squaring 
the circle, and so on, but do not ramble on to such a foolish 
extent. Another difference is this : patients in ordinary 
mania generally hold to their delusions, at any rate for a 
time. The inventor holds to his machine, the grandee to 
his title ; but the paralytic to-day has forgotten his delusions 
of yesterday, and in his eager desire to be great, he increases 
his horses and carriages from thousands to millions, and 
invents half a dozen fresh fancies to add to what he has al- 
ready announced. There is scarcely such a thing as a fixed 
delusion in this stage. It is all happiness, grandeur, and 
wealth in a rapid crescendo, and neither argument nor ridi- 
cule arrests it in the slightest degree. Everything around is 
pressed into the cause, trumpery articles of dress or ornament 
become robes and orders, a cottage becomes a palace, the 
housemaid an empress. Even an asylum, in which the un- 
fortunate man complains that he is confined, is a regal 
abode, and the other patients courtiers and nobles. And 
when strength is failing, and the patient can scarcely stand 
or lift his hand to his head, he tells us that he can write his 
name on the ceiling with a 500 lb. weight hung on his little 
finger. 

Here and there we meet with one who, instead of the 
gayety and excited joyousness which characterize the major- 
ity, presents many of the symptoms of melancholia. Two 
gentlemen have been under my care whose paralytic insanity 
was of this kind. One had many of the commonest delu- 



GENERAL PARALYSIS OF THE INSANE. 275 

sions of melancholia, thought he was going to be arrested, 
that people were about to injure him, that they were ma- 
ligning and going to rob him. Yet he was not melancholic 
as other men are. He never refused his food, but on the 
contrary, was very fond of it, and very particular as to what 
he ate. He had a very good opinion of himself, was very vain 
of his personal appearance, and, with all his melancholy ideas, 
was often quite cheerful and chatty. His mind was dull, 
lethargic, and void of excitement during the whole illness. 
The other patient was very feeble when first admitted, but he 
insisted that he could play the violin at a concert, though 
his left hand was so paralyzed that he could hardly hold a 
book. 

So strong is the feeling of bien etre in these patients, that 
they will declare that they never were better and never 
stronger, when they cannot place their food in their mouths 
or rise from the chair. They remain to the last, throughout 
the gradual degeneration of mind down to the lowest depths 
of fatuity, not only contented, but proud of themselves, their 
position, health, and strength. Even when they are long 
past expressing fixed ideas or delusions, we may recognize 
in vacant dementia their intense happiness. 

Along with the notions of greatness, the delire ambitleux, 
as it has been called, which specially marks this disease, we 
find many of the common delusions of non-paralytic insanity, 
and we may hence conjecture that the seat and origin are 
the same in both diseases. Such delusions as these — "Be- 
lieves himself given over to the devil," "thinks poison is put 
in his food,'' "believes he has committed sins too enormous 
to be forgiven," "thinks he is going to be arrested," — I heard 
from four paralytics. 

You are, then, to recollect that general paralysis is to be 
suspected, if w T e hear a lunatic boasting of his grandeur, 
riches, or strength, especially if his delusions on this point 
are altogether wild, and far beyond the bounds of possibility. 



276 GENERAL PARALYSIS OF THE INSANE. 

To confirm your diagnosis, you will next look for a physical 
paralytic symptom, which is as nearly constant as the ex- 
symptoms. a]^ ideas. If you watch the man closely while 
giving utterance to his boastings, and recounting, in high 
excitement and exuberant spirits, his good fortune and ex- 
ploits, you will notice a defect in his articulation, more or 
less marked, a stopping or stutter in the enunciation of a 
word or the various syllables of a word, which may recall to 
your mind the speech of a man somewhat in liquor, and 
from this circumstance such patients, when disorderly in 
public places, are frequently thought to be drunk. This is 
not the same as stammering, nor is it the defective articu- 
lation of ordinary hemiplegia. The patient is obliged to 
make an effort to get the word out, and possibly is compelled 
to shout it aloud, and then succeeds in saying it distinctly. 
It may be very slight. Dr. Conolly says, that at the very 
commencement " there is in these patients not a stammer, 
no letter or syllable is repeated, but a slight delay, a linger- 
ing, a quivering in the formation of the successive words or 
syllables, apparently from a want of prompt nervous influence 
in the lips and tongue." Not merely in the sound of the 
articulated word will you detect this; the muscular action 
of the lips, particularly the upper, will aid the diagnosis. 
Dr. Bucknill draws attention to a tremulous motion of the 
lips like that seen in persons about to burst into passionate 
weeping. If you closely watch the lips while patients are 
speaking, you will note this tremulousness in some, whereas 
in others you will observe a stiffness and unnatural immo- 
bility of the lips, especially the upper. You will notice also 
a fibrillar tremor of the muscles of the tongue, which is 
jerked in or out in a convulsive manner, as if the patient 
had not full control over it. These are the first indications 
of paralysis, occurring most frequently at about the time of 
the outbreak of decided insanity, sometimes earlier, some- 
times later. For them you will look whenever you meet 



GENERAL PARALYSIS OF THE INSANE. 277 

with a patient whose insanity is marked by exalted ideas 
and delusions that he is a very great man. You may not 
discover the defect of speech on every occasion. Through- 
out the illness you will find that it varies considerably on 
different days, but it is apparent in the majority of cases, 
and, placing our suspicions of the nature of the disorder 
beyond a doubt, enables us to give a certain, but most un- 
favorable, prognosis. We may have paralytics without 
exalted notions, and others in whom we can detect no fault 
of articulation, and concerning these we may hesitate, and 
look further for other symptoms; but where we find the 
stutter and the characteristic delusions, we can have no 
hesitation. 

The defect of speech varies from the slight imperfection 
I have mentioned, which may be overlooked by all except 
the practiced eye and ear of one watching keenly, up to a 
degree which renders the patient absolutely unintelligible ; 
but this occurs later in the progress of the disease. 

The patient becomes more and more altered in habits, 
demeanor, and appearance. A grave parson dresses himself 
in a white hat and a sporting coat ; a decorous father of a 
family walks about the house half-naked, or takes liberties 
with the maidservants — absents himself by night and day, 
buys quantities of useless or absurd articles, or writes letters 
to all manner of people, signing himself King, Duke, or 
Commander-in-Chief. Something soon occurs which leaves 
no doubt in the minds of the friends, and obliges them to 
interfere, and then the patient bursts out into furious mania 
when subjected to control. 

Now, you are to recollect that these patients are for. the 
most part men in their fullest strength — the finest and most 
muscular that we can meet with. We have not now to deal 
with boys or the aged, very rarely with women — never, I 
may say, with ladies. Such men are reckless in their vio- 
lence and resistance beyond any other class of patients. As 



278 GENERAL PARALYSIS OF THE INSANE. 

I have told you, there is an incipient imbecility, which pre- 
vents them from reflecting on what they are about. So, in 
a blind fury, they will attack all around, exerting their mus- 
cular power to the utmost, regardless of all consequences ; 
and they are not paralyzed in their limbs at this stage to 
any extent that will interfere with their violence. Conse- 
quently they are not to be managed out of an asylum, and 
even in one they cause frequently much anxiety. These 
are the patients whose ribs are broken by attendants in 
efforts to overpower them, and who in various ways cause so 

much confusion in asvlum wards. 

*/ 

There are by this time other symptoms which you will 
Epileptiform near °f or notice. The patient may have, or have 
attacks. j iac ^ a «fit/' Sometimes this occurs quite early in 
the disease, before the mind is much affected, and you are 
disposed to think the mental symptoms are due to it. You 
may look upon it as an attack of apoplexy, or epilepsy, accord- 
ing to what you see or hear. Such attacks happen more or 
less frequently in the course of almost every case of this 
malady, which they often divide into stages, the patient never 
quite regaining what he lost by one of them. They are 
called " congestive," or " paralytic," or "epileptiform," attacks. 
They often resemble the petit mat of epilepsy; but sometimes 
reach the intensity of the grand mal, or are of a negative 
character, their presence being indicated not by convulsion, 
but by sudden collapse and paralysis, slowly passing away 
again. Few go from first to last without some of them ; but 
many, especially the younger patients, do not thus suffer in 
the early part of the disorder. There is not the definite fit 
of epilepsy: but we may see convulsions lasting for an hour 
or two, or, if slight, it may pass off without the patient fall- 
ing to the ground. It is important to distinguish this from 
true epilepsy, as the latter is far more amenable to treatment, 
even if complicated with insanity. Patients in the fits of gen- 
eral paralysis seldom bite the tongue, the convulsions are not 



GENERAL PARALYSIS OF THE INSANE. 279 

so violent, there is not the aura, nor the cry, and the mental 
symptoms will, of course, be quite different. 

The attacks resembling petit mal will be followed by much 
graver mental symptoms than those of epilepsy. 

You may also notice that the pupils of the eyes are irreg- 
ular — not always, but very frequently; and when this symp- 
tom is present, it is important and pathognomonic. Dr. Nasse, 
of Siegburg, 1 tells us that of 108 cases of general paralysis ex- 
amined by him, only in three was no irregularity detected. 
Austin found only two exceptions in 100 cases of paralysis. 
You are not to forget, however, that irregularity may exist 
in non-paralytic insanity as it may in sane persons, or in those 
suffering from other affections of the brain. Sometimes, in- 
stead of irregularity, we find both pupils contracted to pin- 
points — a condition which may remain for a considerable 
period, and then be succeeded by irregularity. Some think 
it always precedes the latter, but this is doubtful. 

It has been said that the gait of these patients is peculiar — 
that they walk with a slow, cautious step, short and shuffling 
— that they walk as if about to run, jerking the legs forward. 
But it is not discoverable at an early stage. I have seen 
many whose mental condition was unmistakable, who could 
run, walk, or ride on horseback perfectly well. At an early 
stage we may be able to detect a difference in the handwriting, 
and the defect of mind and memory is shown by the frequent 
omission of words, the repetition of the same sentence, and 
the incoherent jumble of the whole, which differs altogether 
from the coherent though insane letter of an ordinary mono- 
maniac. The writings of these, as of others, often afford us 
most valuable information. 

Now, when a patient in this stage is brought to an asylum, 
what do we see ? He is very angry, very violent, and very 
good-humored by turns, easily pacified and turned aside from 

1 Allgcrneine Zeitsehrift fur Psvchiatrie, 1868. 



280 GENERAL PARALYSIS OF THE INSANE. 

his wrath, but dangerous if not judiciously managed. To- 
gether with his anger there is great silliness about him, and 
his countenance betokens vacancy of mind. He often looks 
stupid and blank while at rest ; and when excited, we may 
notice twitchings and tremors of the various facial muscles, 
for not only the organs involved in speaking, but all the 
muscles of the face, tongue, and pharynx may be more or 
less affected by the incipient paralysis. There is seldom any 
marked hemiplegic symptom, but occasionally I have seen 
ptosis of one eyelid. If this be the case, I should expect to 
hear that there have been epileptiform seizures. Atrophy of 
the optic papilla may be noticed in some patients if we ex- 
amine the eyes with the ophthalmoscope. Sometimes with 
an air of defiance, and sometimes with the greatest delight 
and self-satisfaction, he relates his accession of rank or for- 
tune. By turns he likes or dislikes those about him, will 
make sudden attacks on the attendants in charge, and des- 
perate attempts to escape. He may be in a state of what 
we may call acute mania — noisy, destructive, and dirty, 
breaking windows, tearing up bedding and clothes, and going 
about naked. He may sleep little, yet he will not go many 
days and nights without sleep, so as to cause fatal exhaustion ; 
in fact, it is rare for a paralytic patient to die in this early 
stage, unless he meets with an accident. The less acutely 
maniacal patients often sleep well, and almost all eat well — 
nay, voraciously — bolting their food, swallowing often with 
some difficulty, for the paralysis which affects the tongue and 
lips may extend likewise to the pharynx. Frequently they 
are filthy in their habits, daubing themselves with faeces. 
I consider the maniacal period to be the second stage of 
the disorder in which that of incubation culminates. 

Terminations 

of second After it has lasted for a variable time, from a week 



to a month, or even longer, it generally yields to 
treatment, and one of two conditions follows : either the 
patient gets better, so as to be able to leave the asylum and 



GENERAL PARALYSIS OF THE INSANE. 281 

to pass for a sane man, or the stage of imbecility comes on, 
and he progresses downwards with more or less rapidity to 
extinction of mind and body. 

I have not always found that patients improve in mind 
and body pari passu. Some of those who had the 

1 . Improvement 

best right to be called "recovered in mmd, bore and apparent 
traces of bodily weakness or paralysis — a limp, or 
defect of speech, irregular pupils, or general feebleness, so 
that they were hardly equal to a walk of a mile. In some, 
however, I have seen a wonderful disappearance both of 
bodily and mental symptoms, the improvement lasting for 
some time. These are the cases which are said to be re- 
coveries from the disease. I have seen some who certainly 
would not have been pronounced insane by any jury. They 
had either lost their delusions, or were competent to deny 
and conceal them. I have received letters from them detail- 
ing their travels or amusements, written without a mistake. 
They have spent their money without extravagance, and 
lived in their families as decent members of society. But 
those who had best recovered are long since dead, nor do I 
know one in whom the disease did not reappear in a longer 
or shorter time. Moreover — and this is the real test — I 
never knew one who was capable of work or business. Some 
lived for a time quietly and rationally in country houses, 
but the instant they returned to London and attempted to 
resume their former occupations, they broke down, and were 
obliged again to be placed in confinement. Yet these men, 
had they remained in enforced idleness, might have stayed 
among their friends during the decline of their failing 
strength. The mental defect is essentially mental weakness. 
They are incapable of effort or continued application, and 
deficient in memory, so the attempt causes exhaustion, and 
lights up again the acute symptoms which had been allayed. 
Those who knew them intimately in time past see a differ- 
ence, a slowness or childishness, not apparent to a stranger. 



282 GENERAL PARALYSIS OF THE INSANE. 

I mention this, because you may be asked if you consider a 
patient who has thus apparently recovered from general 
paralysis, competent to manage his affairs. He may desire 
to supersede the commission of lunacy which has placed his 
property in the care of the Court of Chancery, and he may 
ask you to assist him by your affidavit of recovery. His 
improvement, however, is but the semblance of recovery — a 
remission, not the removal, of the disease. It may be quite 
safe to release him from an asylum, and to allow him a cer- 
tain voice in the direction of his household ; but if his affairs 
are of such a nature as to have necessitated a commission, 
they had better remain in statu quo. 

In many cases the cessation of the acutely maniacal symp- 
toms is not followed by the improvement I have spoken of, 
but the patient passes along through a period of chronic 
mania into ever-increasing dementia. Though the excite- 
ment and emotional display are less, the delusions remain. 
He is still a king, a duke, or general ; he issues his orders 
and writes to tradesmen and others, giving commissions to 
the extent of thousands; and though these are never executed, 
and he is kept confined within asylum walls, he never recog- 
nizes the incongruity. He is always going away " to-morrow," 
and to-morrow finds him writing the same kind of letters, 
and doing and saying the same things. The present and the 
future he gilds with his exalted fancy, and of the past he 
takes no heed, frequently caring nothing about family or 
friends. A man in this stage often gets very stout, and re- 
mains so for some time. His strength, mental and bodily, 
varies considerably. Memory is sometimes completely gone, 
sometimes he remembers a good deal, and the articulation 
and power of walking fluctuate in the same way. If he suf- 
fers from an attack of epileptiform convulsions, he loses much 
ground, and for some days may be quite lost and paralyzed, 
often on one side more than the other. This chronic condi- 
tion often lasts a long time, even years. Such patients are 



GENERAL PARALYSIS OF THE INSANE. 233 

always more feeble in cold weather ; in the heat of summer 
they regain strength, often to a surprising degree ; with the 
first frosts they fall back, and, it may be, sink. Whether at 
home or in an asylum they are generally happy and easily 
amused ; the annoyance of to-day, if any arise, is forgotten 
to-morrow T , or can be turned aside without difficulty by calling 
up before them the glories they are expecting in that brilliant 
future which is forever coming. 

We now come to the last stage of all : hopeless dementia, 
utter fatuity. The patient can just walk round the Third stage> 
garden, slowly and shuffling, an attendant holding P ro s res f ive 

° J ° 7 ° paralysis and 

his arm. PI is countenance is vacant and puffy, and dementia. 
he takes little notice of what is said, or of the person speak- 
ing. He begins to get thin, losing the fat which has accumu- 
lated, and if he is confined to bed for a day or two by an 
attack of convulsions, the skin of his back rapidly gives way, 
and the bed-sores resulting are difficult to heal. He can with 
great difficulty hold anything in his hands, which tremble 
like those of a person palsied by age. A symptom frequently 
noticed in this stage is loud grinding of the teeth. For hours 
together a patient will sit and grind his teeth, making a most 
horrible and discordant noise. The appetite is still good, and 
he looks forward to and enjoys his meals. The power of 
deglutition, however, is very feeble, and he will go on filling 
his mouth without swallowing, till he has it crammed full of 
food; and the consequence is that he either gets it impacted 
in the oesophagus so as to compress the larynx, or else it gets 
into the larynx and trachea. From one or other of these 
accidents choking is a very frequent mode of death in these 
cases, and the greatest care ought to be taken that a patient 
shall never eat alone, or in fact without an attendant at his 
elbow, for instant suffocation may be caused by a mass of 
food becoming impacted. The patient now requires to be 
nursed, like any other far advanced in paralysis. There is 
complete annihilation both of bodily and mental activity, and 



284 GENERAL PARALYSIS OF THE INSANE. 

yet by careful nursing even this stage may be prolonged for 
a very indefinite time. And this brings me to another point — 
the duration of the disorder — which often is of considerable 
importance, and on which authorities differ widely. When 
you pronounce an opinion that the insanity is incurable, nay, 
that life itself will soon be extinguished, it may be of the 
utmost consequence to the friends to know the time likely to 
elapse before the latter must take place. If you turn to one 
of the chief authorities, M. Calmeil, you read : " Some para- 
lytic patients live eight months, a year, eighteen months; 
others linger for two or three years, rarely beyond." Dr. E. 
Salomon says : " The course of the disease may extend from 
some months to three years ; in rarer cases it may reach to 
five years, but scarcely ever exceeds that time." Griesinger 
says : " The duration of general paralysis varies from several 
months to about three years." In my own experience I 
should say that the average duration was considerably longer. 
The reason of this is, that my patients have been all of a class 
able to command the best food and nursing. Griesinger says : 
"When nursed in their families these patients live longer 
than in asylums, as they require the same attention in the 
latter stages as a young child." Life may be prolonged for an 
indefinite time by dint of unstinted diet and thorough nurs- 
ing. In the year 1858, a commission of lunacy was held on 
a baronet of large fortune, who was at that time unquestion- 
ably suffering from general paralysis, and who had shown 
symptoms of brain affection and epileptiform attacks so far 
back as 1856, he having been married in 1855. This gentle- 
man is still alive. It is, however, the most protracted case 
I have ever heard of. I should say, that with careful nursing, 
and with every appliance and means for taking care of a pa- 
tient, we might put down the duration of life as from three 
to ^\e years ; but in crowded asylums, and with the diet 
which poorer classes receive, a much shorter period must be 
assigned. 



GENERAL PARALYSIS OF THE INSANE. 285 

Who are the subjects of this malady ? We shall find that 
it is unlike other forms of insanity, for it especially S e X anda g e 
attacks men. Comparatively few women die of it, of P atients - 
and these are almost all of the lower classes : it is the rarest 
thing to find a lady the subject of general paralysis. The 
ratio of liability, according to Dr. Sankey, runs thus: 1. 
Males of the lower classes ; 2. Males of the upper classes ; 
3. Females of the lower classes ; 4. Females of the upper 
classes. Whether the males of the upper or lower classes 
are more liable, is a moot point not easy to be solved. The 
proportion of paralytic patients admitted into a first-class 
private asylum in twelve years was twenty per cent, of all 
the males. M. Calmeil says the males are to the females as 
50 to 15. There are also peculiarities with regard to the age 
of the persons attacked. General paralysis does not make 
its appearance in the very young or the very old, but chiefly 
attacks those in middle life. At the age of 20 we should not 
look for general paralysis; at 25 it is rare, at 60 it is rare, 
at 70 it is unknown; chiefly at 35 or 40 it commences, and 
the patients are not only in their greatest vigor, but often 
fine, handsome, powerful men — men who have enjoyed life 
and have lived hard. We do not find it amongst weak, 
nervous valetudinarians, the subjects of hypochondria and 
melancholia. The paralytic patient has rarely had to seek 
aid from doctors, and in the exuberant feeling of health and 
gayety he derides the notion of there being anything the 
matter with him, and refuses to have anything to do with 
medicine. 

Those who consider general paralysis a special form of 
disease, point to the remarkable fact that it does not attack 
the chronic inhabitants of asylums, or supervene upon other 
forms of insanity. If a young man is insane for a number 
of years, he does not, after a long period of mania or melan- 
cholia, develop symptoms of paralytic insanity. And if a 
patient recovers, and recovers perfectly, from an attack of 



286 GENERAL PARALYSIS OF THE INSANE. 

mania or melancholia, he does not, if he has a second attack 
of insanity, show the symptoms of general paralysis. There 
may be forms of the latter of which the diagnosis is difficult, 
and there may be apparent recoveries which I call .remis- 
sions; but if the disease is really general paralysis, it would 
seem to run a progressive course to dementia and death, 
being throughout a malady resembling in many respects 
ordinary insanity, yet differing altogether in its fatal char- 
acter. 



LECTURE XIV. 

General Paralysis continued — Diagnosis — Illustrative Cases — Diseases 
simulating General Paralysis — Prognosis — Treatment — Post-mortem 
A ppearances — Pathology. 

I now pass to the diagnosis — a matter of the greatest con- 
sequence, seeing that the disease is fatal in such a vast 

. . .... Diagnosis. 

majority of cases. You will have to distinguish it on 
the one hand from less formidable varieties of insanity ; on the 
other from certain other affections which, we are told, may be 
confounded with it. But these are rare, and the diagnosis is 
not difficult. More difficult is it in many cases to say whether 
the insanity of a patient in an asylum is general paralysis or 
not. We may see some patients presenting the delusions of 
general paralysis, whose malady, nevertheless, is ordinary 
mania with exaltation; while others may be paralytic, who, 
nevertheless, lack the best marked characteristics of the dis- 
ease. I lately saw a gentleman, aged forty-six, who 
had been in an asylum about a week, having been trativeof 
brought over from Ireland by the medical man who 
accompanied me. There was no stutter in his speech, no 
tremor or immobility of the lips, no irregularity of pupil, no 
contraction nor dilatation. He had apparently full power and 
perfect co-ordination of both hands and feet. He played both 
billiards and the piano in my presence, and did both well. 
He walked with a long swinging stride, but whether this was 
habitual to him or not I cannot say. Speaking generally, one 
might say that the bodily signs of paralysis were wanting. The 
mental symptoms afforded more information, though these 
were not very marked. He had no very extravagant delu- 
sions, but he thought himself a wonderfully lucky individual, 



288 GENERAL PARALYSIS. 

as he had bought five or six horses for small sums, by which 
he was to realize some hundreds. He was gay and jocose, on 
the best of terms with his friend, though he said that it was an 
infernal shame to have brought him there. He showed loss 
of memory, for he said that he had left Ireland three weeks, 
whereas it was only one. Although told that another physi- 
cian and myself were doctors come to examine him, he never 
tried to persuade us to let him go, though he said he was quite 
well and wanted no doctors. This gentleman was pronounced 
by us to be paralytic: first, on account of the peculiar "larki- 
ness" and hilarity exhibited under the circumstances to two 
perfect strangers who had come to examine him ; secondly, 
his self-satisfaction and ideas of general good luck and suc- 
cess; thirdly, his indifference with regard to being released; 
fourthly, the loss of memory; — all of which went to prove 
that he was suffering, not merely from aberration of intel- 
lect, but from incipient paralytic dementia. Another case 
remained for some time in doubt, and presented in its early 
stages symptoms by no means characteristic of general pa- 
ralysis. In February, 1862, a gentleman was brought to an 
asylum, whose insanity was stated to be of only a few days' 
duration. He had been riding on the pavement and assault- 
ing the police; he was incoherent and rambling; said the 
sun was turned into the moon, and such things, but had no 
grandiose delusions, and was frequently taciturn, not speak- 
ing, perhaps, for a whole day. On alternate days his con- 
dition varied ; on one he was dull and repressed, refused his 
food, and would not speak ; on the other he was gay and 
excited ; but though his conduct was manifestly insane, de- 
lusions were not a prominent feature, and he said little, ex- 
cept that he " wanted to go." He was wet and dirty ; there 
was no stutter, and the signs of general paralysis were mostly 
absent; there was, however, irregularity of the pupils, and 
when he improved somewhat, and talked more freely, it was 
evident that there was great defect of memory. He got so 



GENERAL PARALYSIS. 289 

much better, however, that in July he went into the country 
with his wife, and was reported to be quite well. In the 
following February he was again admitted, and now the 
symptoms of general paralysis were well marked. His sons 
were dukes, he was worth millions, and so on. There were 
great doubts as to the nature of the disorder at the commence- 
ment, and only the irregularity of the pupils, the defect of 
memory, and general absence of mind, made the prognosis 
unfavorable. This gentleman complained constantly of pain 
in the head. When said to be recovered he remained in the 
country idle : the moment he resumed work the symptoms 
returned, and this time with unmistakable features of the 
disorder. 

Not long ago I saw a gentleman from whose extravagant 
delusions one might have imagined that he was the subject 
of general paralysis. He boasted of his extraordinary intel- 
lect and strength. He was going into Parliament, and, as a 
preliminary step, was to assemble 10,000 people in his park, 
have them photographed, and sell the photographs at five 
pounds apiece, thus paying off the mortgages on his estate, 
and making £100,000. He thought that people might live 
a thousand years if they bathed in beef-tea and beer, wanted 
to make a tunnel through the earth to the antipodes, and 
various things of this kind. He was dressed in a most ex- 
traordinary costume, and was insane beyond all question. 
Yet there was no stutter and no loss of memory, and I heard 
that he had had, and had recovered from, a similar attack in 
India some years before. This was conclusive to my mind. 
Had the former attack been general paralysis, he could not 
have recovered. The mania which had passed away before 
might pass away again, and so in the sequel it proved. 

Another gentleman was pronounced paralytic, and cer- 
tainly there were many symptoms of this disorder. He had 
been spending money in a most reckless manner, but he 
defended all he had done. He thought himself a man of 

19 



290 GENERAL PARALYSIS. 

rank, and had a ducal coronet engraved for his paper and 
envelopes. He was gay and expansive, although he knew 
he was under legal restraint, quarrelled with his friends, and 
vet joked with them, and at times there appeared to be a 
slight hesitation in his speech. I doubt if any oue could 
have pronounced unhesitatingly on one inspection that this 
was or was not a case of general paralysis. Against it was 
his age. He was upwards of sixty. He had long suffered 
from acute bodily disease — disease of bladder and kidneys 
consequent upon stricture, and in the midst of it mental 
symptoms showed themselves. But paralysis rarely attacks 
a man weakened by other disease, while it is common for 
ordinary mania to commence in such a subject. Time very 
soon made it plain that it was not paralysis. Though the 
bodily health got worse, the mind did not. Instead of para- 
lytic delusions appearing and becoming more and more ex- 
travagant and absurd, all delusions disappeared, and there 
remained what we may term moral insanity, a weakness and 
degeneracy of mind shown in a desire to waste money and 
buy useless articles, to tell indecent stories, and generally to 
behave himself in a way the reverse of what he formerly 
had done. So matters went on till his death, no other symp- 
toms of paralysis ever appearing. I believe the apparent 
stutter was due to nervous agitation, when obliged to discuss 
his conduct with strangers in his extreme state of bodily 
weakness. From the same cause he not unfrequently shed 
tears. Had this gentleman's bodily ailments been curable, 
I have no doubt that his mental aberration would have been 
removed. You will recollect that when a patient is over 
sixty the symptoms of general paralysis are to be examined 
with great care, and we are to doubt them unless they be of 
a most clear and unquestionable character. In this last case 
there was no irregularity of pupils, no difficulty of walking, 
no loss of memory ; above all, the patient wrote an excellent 
formal business letter without leaving out a word or making 



GENERAL PARALYSIS. 291 

mistakes of any kind. Such letters would by themselves 
almost decide the point. 

The cases of non-paralytic insanity about which there may 
be doubt, are not chronic cases of mania or dementia. They 
are recent cases of mania, with exalted delusions, or what is 
termed moral insanity, with extravagance and indecent con- 
duct. Here you will look for loss of memory, hesitation in 
speech, defects in letter-writing, especially words left out or 
repeated, irregularity of pupils, tremor of lips and other facial 
muscles, and possibly a slow or halting gait. You will con- 
sider the sex and age of the patient, the history, the occur- 
rence or non-occurrence of former attacks, or of epileptiform 
seizures. If the patient some years ago has recovered, and 
thoroughly recovered, from some similar attack, and has 
since gone about his work like any one else, the disorder is 
not paralysis. 

There is a malady occasionally seen in asylums which re- 
sembles in some respects general paralysis, but is p ar aiy S isof 
easy to be distinguished. This is a paralysis pro- alcollolism 
duced by chronic alcoholism. The two features in which 
it most resembles the disorder we are discussing are loss of 
memory, and loss of muscular power and co-ordination. This 
condition is not uncommon among females, as I have already 
mentioned : we find it to be the end and result of continued 
dram-drinking. They do not develop delirium tremens so 
frequently as men, but this form is not uncommon; but as 
we find it amongst ladies, so do we not find general pa- 
ralysis. It is only the rarer forms of the latter malady that 
resemble chronic alcoholism, those distinguished by a melan- 
cholic rather than an expansive state. The muscular weak- 
ness does not in alcoholism extend to the organs of articula- 
tion. I have known several patients who could hardly stand 
w T ho spoke quite distinctly. The delusions of such chiefly 
depend on the entire obliteration of memory. The patients 
want to see and visit people who have long since died ; and 



292 GENEEAL PARALYSIS. 

when told of this, when the circumstances are brought back 
to their recollection, they make the same request five minutes 
after. Except for the absence of the stutter, the muscular 
defect may be much the same, but the mental symptoms are 
rarely alike ; and if you make a close investigation of the 
commencement of the disorder, its history, and supposed 
cause, you can hardly make a mistake. 

We sometimes find acute delirium breaking out in patients 
Lead poisoned by lead, and with it there may be the 

paralysis. paralysis produced by that substance. The de- 
lirium, however, is usually transient, the palsy does not 
affect the speech, the history and the blue line on the gums 
will assist our diagnosis, and the peculiar exalted delusions 
will be absent. 

Senile dementia, which may commence at a comparatively 
senile early age, may be characterized by loss of memory, 

dementia, extravagant and indecent conduct, and delusions. 
There will, however, be an absence of the specific delusions 
and the maniacal condition; neither shall we find the in- 
equality of pupils, the stutter, nor stumbling gait. In fact, 
the failing mind in senile dementia is manifested usually long 
before any symptoms of bodily paralysis, and you will recol- 
lect that general paralysis is rare at the age of sixty, senile 
dementia seldom beginning so soon. 

But we may meet with dementia or mania following 
apoplexy or hemiplegia, and may notice a stutter in the 
speech, a defective walk, loss of memory, and dirty habits. 
The patient, however, presents none of the mental symptoms 
of general paralysis. If the condition is one of dementia, he 
will be dull, vacant, torpid, with none of the bien etre and 
expansiveness that characterize insane paralytics. If he be 
maniacal, the special delusions will be wanting, and when 
the mania passes off, the difference will be clearly seen. 
Moreover, we shall learn a history which will leave no doubt. 
The paralytic attack will have preceded the mental symp- 



GENERAL PARALYSIS. 293 

toms, whether these be maniacal, or only the imbecility of 
dementia, and the paralysis will be the result of a sudden 
attack, not of a slowly advancing progressive disease. 

Mania and dementia, the result of epilepsy, may be con- 
founded with the state of a paralytic patient who Ep iie P tic 
has lately had an epileptiform seizure, which you P aral >' sis - 
may be told was an epileptic fit, or series of fits. Here the 
history of the patient previous to the fit will be our best 
guide. Were there at that time any of the characteristic 
delusions of general paralysis? I was called to a gentleman 
who had had a seizure of this kind. He was lying in bed, 
not able to stand alone, or to lift his food to his mouth ; he 
kept repeating one word, and was quite childish and lost. 
But for the previous history, it would have been difficult to 
say what was the origin of this paralytic dementia. Yet a 
few questions made it perfectly plain, and it was possible to 
say that in a few days he would be walking about again, but 
that he would not live beyond a year or two. He did not 
live a year. An attack of mania following epilepsy generally 
subsides in a week or less, and then the patient returns to 
the state he was in prior to the fit. His mental condition will 
at no time resemble that of a paralytic patient, though he 
may be very furious and dangerous. There will be no self- 
satisfied contentment or exaltation, but rather angry sus- 
picion, rage, or panic, leading him to homicidal or suicidal 
violence. When this subsides, he may be apparently well 
and restored to reason, whereas the paralytic will show the 
effects of the seizure for a long time, and probably will never 
regain his former mental power. 

Locomotor ataxy and other disorders affecting the muscular 
powers are not likely to be confounded with general paralysis 
of the insane, inasmuch as mental symptoms are wanting. 
I shall hereafter have to consider whether the paralytic symp- 
toms of the latter disorder ever precede the mental. On this 
point there is considerable difference of opinion. 



294 GENERAL PARALYSIS. 

In concluding the subject of diagnosis, I would say that 
cases are occasionally seen which must be looked upon as 
instances of spurious ov pseudo general paralysis. The symp- 
toms and course of the disease do not present the usual 
appearances, and by one observer it may be called general 
paralysis, while another would deny it the right to this title. 
Such cases are of great importance in estimating the pathol- 
ogy, and would seem to support the opinion of those who 
hold that it is not a special variety of insanity, but that it is 
insanity plus a number of symptoms of paralysis, cerebral 
and spinal, which, like the mental, may vary indefinitely. 

If the diagnosis leads us to the conclusion that the patient 
is suffering from general paralysis, it follows that 
the prognosis must be extremely unfavorable. Prac- 
tically, we look upon the disorder as fatal, and probably fatal 
in three or four years. Indeed, it is a question whether any 
have ever recovered from it. Patients are dying of it in all 
our asylums by the hundred, yet our best authorities record 
no recoveries. Here and there we may see a patient who is 
said to have recovered ; but unless a long period has elapsed, 
we cannot be sure that the recovery is anything more than 
a remission. 

The consideration of the pathology brings me to another 
point. Can we in any way account for the disease ? 

Causes of *■ ■/ •/ 

general what is its cause in any one individual ? I have 
held for some years the opinion, based altogether 
on my observation of cases, that sexual excess has more to 
do with the causation of it than anything else. It is difficult 
to get at the history of this excess. If a man has led a very 
loose life, we may hear of it ; but there may be great excess 
in married life, and of this we hear little. I have known 
several cases where the patients were men not very young, 
who had married young wives, having in former days led 
very dissipated lives. One man had been a great mastur- 
bator, and when married had never had complete intercourse, 



GENERAL PARALYSIS. 295 

but had broken down in constant attempts. Some had led 
lives of great profligacy, which they had carefully concealed 
from everybody. And when we speak of sexual excess, it is 
not to be forgotten that what is excess to one man may not 
be to another. As one drinks with impunity an amount 
which kills another, so sexual indulgence which is harmless 
to this man may produce disorder in that. These observa- 
tions of my own are confirmed both by the opinion of others, 
and by various circumstances to which I would draw your 
attention. General paralysis does not attack the young, or 
the old, and is not in general found amongst the weakly, but 
rather invades the strong and vigorous, those most likely to 
be guilty of excess. It rarely attacks women, especially of 
the higher classes. I myself have no experience of female 
paralytics ; but Dr. Sankey, who was the superintendent of 
the women's side at Hanwell, and has made this disorder his 
special study, tell us, 1 "it is remarkable how many of them," 
that is, the women, u had led irregular lives, and especially 
had been guilty of sexual impropriety of some sort;" and he 
gives the particulars of seven cases. He, moreover, tells us, 
"out of 34 cases, of which the history of the disease is com- 
plete, 11 are known to have led an habitually irregular life 
with respect to sexual indulgence, and of 14 only was the 
information satisfactory as to the contrary state of things ; 
even of these 14, one had borne an illegitimate child in early 
life, but since, according to her mother, had lived correctly; 
and one other was a married woman who had left her hus- 
band on the day after her marriage." 

Next, I have to speak of the treatment of these patients. 
Although we do not cure them, although the dis- 

i . i 7 . 7 . Treatment. 

order is still one of the opproona meaicorum, we 

must never give up the attempt. One cannot understand 

as yet why this progressive disease should not be arrested, 

1 Lectures on Mental Diseases, p. 181. 



296 GENERAL PARALYSIS. 

for clearly the remissions and recoveries are at times so great 
that very little of the disease can be left, although the ten- 
dency to recur may be there, as in other forms of insanity. 
At any rate, our object in every case is to restore the patient 
to his friends, and enable him, if their means allow, to pass 
the close of his life amidst his family. These patients are 
rarely to be managed out of an asylum in the early stage. 
If they are wealthy, and a complete establishment can be 
provided, they may be so surrounded that they are virtually 
in an asylum for one ; otherwise, they are better off in a well- 
conducted asylum, and quite as happy. At the outset, when 
first restrained, they are subject to paroxysms of blind, im- 
becile fury and violence, and are at this time very dangerous, 
requiring the appliances and skilled officers of an asylum. 
They also require exercise within secure grounds, and this 
they can rarely obtain elsewhere. And they are so elated by 
reason of their malady, that they do not feel restraint like 
other patients, who are more conscious of their position. 
They write myriads of letters, ordering horses, carriages, and 
diamonds, and never wonder why they are not sent, and why 
they get no answer. When by nature good-humored and 
pleasant people, no patients so enjoy themselves in an asy- 
lum, or are so easily pleased and humored. A promise that 
what they want shall come some day, turns aside their pres- 
ent ill-temper, and their failing memory has the next moment 
forgotten the desire. They are childish and childlike in 
mind, and can be led like children by tact and kindness. 
They are, at the same time, dangerous and treacherous. 
Their weak mind regards not consequences, and they will 
set fire to the house, or secrete a stone, or some such article, 
to attack the object of a delusion. One can never trust them : 
many patients we may believe implicitly, these we cannot. 
Much may be done by medicine in the violent excitement 
which characterizes the early stages of the disorder ; and the 
drug which above all others seems to act beneficially here is 



GENERAL PARALYSIS. 297 

digitalis, which is largely given in our public and private 
asylums: administered in doses of rrgxv to ffRxxx of the tinc- 
ture, repeated, if neecessary, every three or four hours, it 
often produces a wonderful effect, soothing their noisy tur- 
bulence, and restoring them to a comparative state of ration- 
ality, so that they cease their destructive habits and filthy 
practices, wear clothes in decent fashion, and take food. 
Formerly, tartar emetic was given for this purpose; but it 
cannot be continued like digitalis, and I believe the latter 
to be now almost universally used. In some cases opium and 
morphia are serviceable, and frequently we may give them in 
conjunction with digitalis with greater benefit than alone. 
In the latter stages of dementia, where we find often great 
restlessness and want of sleep, along with an advanced stage 
of paralysis and prostration, opium or morphia maybe given 
without digitalis ; and for the mere production of sleep, chlo- 
ral is as valuable here as in other forms of insanity. 

I know no other sedatives that are worth a trial in this 
disease, unless it be bromide of potassium. This I have not 
given in large doses to paratytics, as I look upon its effect as 
decidedly enfeebling. It may be given, however, in doses of 
10 or 20 grains with benefit when epileptiform attacks are 
recurring frequently. 

Some years ago it was the fashion to administer to these 
patients the bichloride of mercury. General paralysis was 
an inflammation: mercury arrested inflammation, therefore, 
paralytics took mercury. But I never saw the least good 
done thereby in the many cases where it was tried. Tonics, 
on the contrary, are often of the greatest service when the 
great excitement has passed away; and, as in other head 
cases, I believe no tonic equals iron and its preparations. 
Quinine and bark seem of secondary importance ; but iron — 
the tinct. ferri perchloridi especially — often seems to infuse 
new vigor into the failing limbs of the paralytic. 

In the height of the excitement, beware how you give 



298 GENERAL PARALYSIS. o 

stimulants, especially brandy. It renders them furious, de- 
prives them of sleep, and undoes the effect of other remedies. 
As in acute delirium, give at first the more soporific stimu- 
lants, stout and ale, if you give any, and reserve your brandy 
and wine until a later period. When the excitement has 
passed off and reason is returning, and friends are beginning 
to think that, in spite of your gloomy predictions, the patient 
is recovering, he will require a generous diet, with a liberal 
supply of port wine. And this must be continued during the 
whole period of his convalescence and subsequent decline into 
dementia; and the latter will, cceteris paribus, be prolonged 
according to the plenteousness of the food taken. About this 
time of gradual decay there is little to say here. Such pa- 
tients must be nursed according to the ordinary rules of nurs- 
ing. They must not be allowed to lie in bed. They must 
be taken out of bed, thoroughly washed — for in the advanced 
stage it is very difficult to keep them dry — and must sit by 
day in an easy chair, and, so long as they are able, taken for 
a walk in the garden, or a ride. If allowed to lie in bed, 
they will very soon contract bed-sores, which, in their condi- 
tion of depressed vitality, will be most difficult to cure. A 
strong solution of sulphate of zinc forms a good lotion when 
the skin is threatening to give way. When it has happened, 
I know no better application than the oxide of zinc, thickly 
strewn in powder on the sore, which by repeated dredgings, 
may be coated over and preserved from the air, and thus will 
often quickly heal. 

Considering the opportunities afforded for post-mortem ex- 
amination of patients dying of this disease, it may seem 
strange that doubt should still exist as to its seat, and special 
Post-mortem pathological character. Every portion of the brain 
appearances, ^s been thought to be the part affected. The early 
discoverers looked upon it as a chronic meningitis, and this 
view has been reproduced in our own times by L. Meyer. 
Calmeil, who did so much for its accurate description, thought 



GENERAL PARALYSIS. 299 

it an inflammation of the cortical portion; and quite lately 
Dr. Meschede, in addition to many others, has held the same 
opinion. The cortical substance by some is supposed to be 
affected by atrophy, and pigmentary and fatty degeneration 
of the cells, while by others the morbid change is thought to 
be an increase of the connective tissue, invading both the 
gray and white cerebral substance. Changes in the blood- 
vessels of the cortical substance have been pointed out by 
various observers in cases of general paralysis, changes in the 
walls of the vessels, increase of the nuclei, twisting and 
aneurismal dilatations of the arteries and capillaries, and ob- 
literation and amyloid degeneration of them. Others point 
to an atrophy of the nerve-tubes, and to degeneration of the 
white matter ; while Dr. Lockhart Clarke describes holes or 
vacuoles, seen by him in various portions of the white matter 
of the brain as well as of the convolutions. These he believes 
to be perivascular spaces or canals, which originally contained 
bloodvessels, surrounded by their peculiar sheaths, and which 
subsequently became empty by the destruction and absorp- 
tion of those vessels. I have already spoken of these in my 
fifth lecture. 

The majority of observers have described only the morbid 
appearances found in the brain, which they have considered 
the seat of the disorder. But others, as Drs. JofTe, Boyd, and 
Westphal, have called attention to the diseased condition of 
the spinal cord. The last named has described minutely the 
morbid processes thereof: he has found inflammatory disease 
of the spinal dura mater (pachymeningitis), alteration, opacity 
and thickening of the pia mater, and three different forms of 
disease of the cord : (1) disease of the posterior columns only 
throughout their length, from the cervical to the lumbar re- 
gion, consisting of an atrophy of the nerve-tissues, and a 
growth of connective tissue which sometimes takes the place 
of the nerve-tubes, the morbid process being specially devel- 
oped at the periphery of the posterior columns. In addition 



300 GENERAL PARALYSIS. 

to this we find (2) an affection of the posterior section of the 
lateral columns throughout their whole extent, and (3) a 
mixed form of affection of the posterior columns and of the 
posterior portion of the lateral columns. In the two latter 
varieties Dr. Westphal looks on the disease as a chronic 
myelitis. There are present nucleated cells, and a reticulated 
network of connective tissue surrounding the nerve-tubes ; 
but the large plates of connective tissue are not found as in 
the first variety. Dr. Westphal does not connect these ap- 
pearances pathologically with the diseased conditions found 
in the brain. He considers that the disorder does not spread 
from the brain downwards, or from the cord upwards, for he 
has not found disease in the mesocephalic parts. "If we con- 
sider all the circumstances, we must for the present regard 
the cerebral and spinal diseases which simultaneously ex;ist 
in general paralysis of the insane as, in so far, existing per se, 
and in certain respects independent of each other, as it is im- 
possible for us to define more minutely the nature of the 
cerebral malady, and to establish a connection between it on 
the one hand, and the processes of gray degeneration and 
chronic myelitis of the spinal cord or medulla oblongata on 
the other." 

The history of the investigation of general paralysis is 
this: observer after observer has found some morbid appear- 
ance which he has thought pathognomonic of the disease, but 
which has been found to exist in the brains of other insane 
patients, or even in the brains of those not insane. Although 
the symptoms during life may make us think that there must 
be a progressive chronic inflammatory degeneration, leading 
to a decay of normal structure, and to a development of more 
lowly organized tissues ; yet, so far, although very careful 
observers have examined the brains of paralytic patients, 
they have not found the actual pathological condition of this 
most interesting yet fatal disease. As I have said, this is 
partly due to the fact that the sufferers rarely die in the 



GENEKAL PAKALYSIS. 301 

early stage. Where opportunities occur for examining a 
brain of a patient dying at a very early period, the actual 
seat of the mischief, whether cerebral or spinal, maybe more 
certainly defined. 

Lastly, we have to consider the nature of this mysterious 
disease, of which we know no cure, which crushes 

.. ..,, Pathology. 

the strongest in his lull prime, terminating both 
reason and life. Patients die of it by hundreds in our asy- 
lums, yet its pathology is not yet ascertained beyond dispute, 
and various questions arise on which authorities are not 
agreed. First, is general paralysis a distinct disease ? To 
this some, chiefly the French, reply in the affirmative, while 
others, especially the Germans, hold that the paralysis may 
be a complication of insanity, or the insanity a complication 
of a general condition of paralysis. 

The discrepancies in opinion are in truth caused by our 
ignorance of the essential pathological condition of insanity : 
were this ascertained beyond all doubt, we should be able to 
decide on the identity or difference of the disorder called 
general paralysis. Looking at the clinical examination of 
the latter, we may notice, first, that we find the same mental 
symptoms in paralytic as in non-paralytic insanity, the same 
delusions, the same joyous excitement, the same depression, 
the same dementia, gradually, but more rapidly, advancing. 
Whence we infer that the same portion of the brain is 
affected in both diseases, and affected in a manner closely 
alike. Then arises the question, does the one and the other 
disease commence in the mind-region of the brain, i. e., in 
the cerebral hemispheres, or can it be that disease of some 
more distant organs, such as the sensory ganglia, the medulla, 
spinal cord, or vaso-motor ganglia, produces a disturbance of 
the mental organ. May we conceive that a disorder arises 
in the vaso-motor ganglia, which, subsiding in ordinary in- 
sanity, allows of recovery; but in the paralytic affection 
progresses from ganglion to ganglion, thus interfering by 



302 GENERAL PARALYSIS. 

degrees with the whole of the nerve-organs, and leading 
gradually to degeneration and disorganization? The con- 
dition of the vaso-motor ganglia in insanity has been scarcely 
spoken of, yet I may quote the words of Drs. Poincare and 
Henry Bonnet, who in the "Annates Medico-Psychologiques," 
tome xii, 1868, make these observations on them : " In gene- 
ral paralysis the cells of the whole chain of the great sympa- 
thetic are covered with brown pigment to a degree much more 
intense than in other subjects, from whatever affection they 
may have suffered. In the ganglia of the cervical region, 
and often in the ganglia of the thoracic, there is evidently a 
substitution of cellular tissue and of adipose cells for the 
nerve-cells, which last are comparatively rare. Everything 
leads us to think that this is the anatomical starting-point 
of the affection, and that the alterations of the encephalon 
are the mere consequences of the disorders which this schle- 
rosis, by a paralytic action of the cervical ganglia, produces 
in the cerebral circulation. There is always a very marked 
pigmentation of the spinal ganglia and of those which are 
attached to the cranial nerves. The adipose cells, which are 
substituted for nerve-cells in the ganglia of the great sym- 
pathetic, often exhibit a depth of color which may even be 
quite black." 1 

These observations may explain differences which exist in 
the opinions of various writers. There can be no question 
that coexisting with the mental affection there is a gradually 
advancing paralysis. Then, we ask, does the disease extend 
downwards from the brain to the cord, or upwards from the 
cord to the brain ? do we find paralytic symptoms existing 
before any mental derangement, or do we notice the peculiar 
mental delusions for some time before there is any defect of 
speech or gait ? or is the one set of symptoms always accom- 
panied by the other? Now, I think it may be stated as 

1 Translated in the Journal of Medical Science, July, 1869. 



GENERAL PARALYSIS. 303 

certain, that motor disorder may be noticed before any men- 
tal symptoms. A gentleman whom I saw in an asylum had 
had a paraplegic affection for ten or twelve years. His 
speech was not impaired, and there was no mental disturb- 
ance till ten days before I saw him. He then spent money 
recklessly, thought he had commands from heaven, and his 
speech was most inarticulate. The spinal symptoms have 
been, by Dr. Westphal, divided into tabic, when we find gray 
degeneration of the posterior columns with a loss of nerve- 
substance and substitution of connective tissue, and paralytic, 
in which the process appears to be a chronic myelitis. In 
the latter form, the symptoms of motor disorder are more 
latent, and may be noticed as a weakness or lassitude only. 
The tabic form of gait may exist in patients who have no 
mental disorder, so that it cannot necessarily depend on the 
cerebral disease ; the paralytic form may be hardly notice- 
able, even if it exists, whereas, at the same time the mental 
symptoms may be most marked. There is every reason for 
supposing that the mental and motor disorder depend on 
pathological states which, though they coexist, are indepen- 
dent one of the other. 

The epileptiform or apoplectiform attacks, the convulsive 
tremors noticeable throughout the disease, the appearance 
and disappearance of the affection of speech, and other para- 
lytic symptoms, all point, in my opinion, to sudden interference 
with the circulation, which may depend on disturbance of 
the vaso-motor system. To the observations already recorded 
by Drs. Poincare and Bonnet I may add the opinion of Dr. 
Westphal : "Considering that we have been studying a series 
of changes in certain columns of the spinal cord, in the me- 
dulla oblongata, pons varolii, and crus cerebri, the supposition 
is not improbable, that through a temporary excitation (due 
to the morbid process) of the vaso-motor nerves proceeding 
from these parts, the anaemias we have mentioned may be 
produced. Further speculation on this point, however, can 



304 GENERAL PARALYSIS. 

lead to nothing until further physiological facts have been 
obtained." 1 

It is too much to assert that the seat of disease is in these 
ganglia, nevertheless they demand more investigation than 
they have as yet received. 



1 On General Paralysis of the Insane, by Dr. C.Westphal, translated from Gries- 
inger's Archiv. fur Psyehiatrie, No. 1, in the "Journal of Mental Science, 1868." 



LECTURE XV. 

Of Patients whose Insanit}^ is doubtful — Insanity without Delusions — 
Are Delusions the Test of Insanit}'? — On Moral Insanity, so called — 
Dr. Prichard — His Illustrative Cases considered — Intellectual Defect 
in the Morally Insane — Moral Insanity in connection with Epilepsy 
and Old Age— Emotional Insanity — Prognosis and Treatment — On 
the so-called Legal Test, the Knowledge of Right and Wrong. 

Hitherto I have spoken of patients whose insanity is plain 
and unmistakable. The question for us is, how are we to 
cure them. As, with the exception of the paralytic patients, 
the insanity is recent and acute, we shall be able to cure a 
considerable number. But there are many persons 
about whom your opinion will be sought on other ^^ ents 
grounds. frTou will have to say, either to the friends insanit > ta 

° J 7 doubtful. 

or in a court of law, whether a patient is or is not 
legally of unsound mind — so unsound in mind as to be in- 
capable of taking care of himself and his affairs, and a fit and 
proper person to be detained under legal restraint. Most 
difficult is it in many cases to come to a decision upon such a 
question ; still more difficult to give the grounds of our opin- 
ion, and to give them publicly in the witness-box. Your 
opinion will be required, speaking generally, for one of four 
purposes : 1. To place a patient under legal restraint in an 
asylum or quasi-asylum for the purpose of treatment; 2. To 
deprive a man of the management of his affairs by a com- 
mission de lunatico inqidrendo ; 3. To relieve a patient from 
the responsibility of some crime committed or contract en- 
tered into; 4. To inquire into the state of mind of a testator 
at the time he executed his will. The legal portion of the 



Insanity 
without 
delusions. 



306 INSANITY WITHOUT DELUSIONS. 

subject I shall leave till hereafter. I wish now to bring 
before you certain classes of patients and certain varieties of 
insanity which most frequently give rise to forensic contests. 
These are "moral insanity," " emotional," and "impulsive 
insanity." Under these names you will find cases quoted in 
books, and 3^011 may be questioned concerning them by coun- 
sel. Such patients may be more accurately described by 
other names, and I wish to indicate to you the method of 
examining and testing them. 

Certain forms are discussed in courts of law, and hotly con- 
tested, because they are said by some to lack the symptoms 
necessary to be demonstrated before we can pronounce any 
one legally insane. Chiefly, the absence or presence of delu- 
sions is the point at issue. Can a person be found 
lunatic who has no delusions? Most lawyers deny 
this, even now. Our own profession affirms it, and 
points to many persons of undoubtedly unsound mind, in 
whom no delusions are to be found. 

In reading the history of the great cases of disputed in- 
sanity, you may be astonished to find that what is considered 
unsoundness of mind in a civil cause is by no means looked 
upon as legal insanity in a criminal trial. That which is 
deemed proof of a man's being unable to manage his affairs, 
does not necessarily absolve him from responsibility if he has 
committed murder. When giving evidence upon a commis- 
sion in lunacy, you are asked, in plain terms, if you think the 
patient is fit to take care of himself and manage his affairs — 
a question which the facts of the case generally render easy 
to answer. But, in a crown case, you are asked if the prisoner 
knew what he was doing when he committed the crime, or 
if he knew right from wrong, and such questions, which are 
totally irrelevant and beside the issue, which is, was he of 
unsound mind when he committed it. I shall have to refer 
to this again, but I mention it here inasmuch as the proof of 
insanity in criminal cases must be stronger than in others, 



INSANITY WITHOUT DELUSIONS. 307 

and this must be borne in mind by all of us who may be called 
upon to give evidence. 

Lawyers and judges vary indefinitely according to their 
humanity and idiosyncrasy in their opinions as to what con- 
stitutes irresponsibility. Some say that a patient is respon- 
sible unless he is so insane that he cannot know nie ga i re- 
right from wrong, others hold that he is not insane s P° nsibilit y- 
unless he has delusions. This latter theory is constantly 
propounded in both civil and criminal courts. It was held 
and believed at one time by both lawyers and doctors. If 
we look back at the definitions and doctrines of the great 
medical luminaries of the seventeenth and eighteenth cen- 
turies, we shall find that they almost invariably divided 
insanity into melancholy and mania, which latter they also 
called phrensy or fury. Melancholy they defined to be " a 
permanent delirium, without fury or fever, in which the 
mind is dejected and timorous, and usually employed about 
one object." "Mania is a permanent delirium, with fury 
and audacity, but without fever." 1 

Now delirium in Arnold's time, 1782, did not mean what 
it does nowadaj s. You know very well what the delirium 
of fever is, or delirium tremens. We should not say that a 
monomaniac laboring under the delusion that he was the 
rightful heir to the throne, but in all other respects rational, 
was suffering from delirium, yet this would have been de- 
scribed as his malady by the writers of the last century. 
Delirium sine fehre was oar " delusion," delirium cum febre 
was our " delirium." " Phrenitis," says Hoffman, "est in- 
sania cum febre, a stasi sanguinis inflammatoria in vasis 
cerebri orta." 

Melancholy by the older writers as far back as the time of 
Burton, is used to signify monomania or partial insanity, in 
contradistinction to mania, which meant general insanity, 

1 Vide Arnold on Insanity, vol. i, p. 30. 



308 INSANITY WITHOUT DELUSIONS. 

fury, or phrensy. This distinction between general and 
partial insanity we hear maintained by lawyers in our own 
day, and we can trace it back at any rate so far as the seven- 
teenth century, for Lord Hale says 1 — " There is a partial 
insanity and a total insanity. The former is either in re- 
spect to things, quoad hoc, vel illud iusanire. Some persons 
that have a competent use of reason in respect of some sub- 
jects, are yet under a particular dementia in respect of some 
particular discourses, subjects, or applications, or else it is 
partial in respect of degrees ; and this is the condition of 
very many, especially melancholy persons, who for the most 
part discover their defect in excessive fears and griefs, and 
yet are not wholly destitute of the use of reason ; and this 
partial insanity seems not to excuse them in the committing 
of any offence for its matter capital, for, doubtless, most per- 
sons that are felons of themselves and others are under a 
degree of partial insanity when they commit these offences. 
It is very difficult to define the invisible line that divides 
perfect and partial insanity ; but it must rest upon circum- 
stances duly to be weighed and considered, both by judge 
and jury, lest on the one side there be a kind of inhumanity 
towards the defects of human nature, or on the other side 
too great an indulgence given to great crimes." 

Here Lord Hale lays down the doctrine that partial in- 
sanity, melancholy, or monomania, does not absolve from 
responsibility in criminal cases. Those lawyers who do not 
go so far as to say this, but would allow that insanity of any 
kind absolves a man from punishment, nevertheless almost 
all assert that to prove insanity we must prove delusion. 
This opinion is maintained both by civil and criminal lawyers, 
and I have heard it enunciated frequently within the last 
few years. Two legal opinions I may quote, given by men 
of great eminence on this side. The first is that of Sir John 

i Pleas of the Crown, 30. 



INSANITY WITHOUT DELUSIONS. 309 

Nicholl, whose judgments are highly esteemed and honored 
by all lawyers. In a very celebrated judgment pronounced 
by him in the Court of Probate, in Drew v. Clark, he said — 
"The true criterion, the true test of the absence or presence 
of insanity, I take to be the absence or presence of 
what, used in a certain sense of it, is comprisable J^ngconsid- 
in a single term, namely, delusion. In short, I e f d the * est 

° 7 J 7 'of insanity. 

look upon delusion, in this sense of it, and insanity, 
to be almost, if not altogether, convertible terms. On the 
contrary, in the absence of any such delusion, with whatever 
extravagances a supposed lunatic may be justly chargeable, 
and how like soever to a real madman he may think or act 
on some one or all subjects; still, in the absence, I repeat, of 
anything in the nature of delusion, so understood as above, 
the supposed lunatic is in my judgment not properly or 
essentially insane." 

Mr., afterwards Lord, Erskine, at the trial of Hadfield, 
who shot at the King in Drury Lane Theatre in the year 
1800, said — "Delusion, when there is no frenzy or raving 
madness, is the true character of insanity; and when it can- 
not be predicated of a man standing for life or death for a 
crime, he ought not, in my opinion, to be acquitted." 

This is the opinion of many, I may say most, lawyers. 
But lawyers, I need not tell you, have no practical acquaint- 
ance with the insane. Their doctrines are based on the tra- 
ditions and judgments of preceding dignitaries, and in no 
way depend on the advance of scientific research or more 
accurate observation of patients. I shall endeavor to show 
that many patients, undoubtedly of unsound mind, have no 
delusions, that delusions are not the one "test" of unsound- 
ness of mind, nor even of insanity so called ; and, further, 
that there are many who are beyond all question of unsound 
mind, who cannot properly be called insane. Counsel will 
try to trip you on this point, and ask if you consider the 
patient insane. He may not be insane, strictly speaking, 



310 INSANITY WITHOUT DELUSIONS. 

and you may have to admit it; they will then argue that he 
is not legally of unsound mind. But a great lawyer, Lord 
Coke, in his commentary upon Littleton, forestalled this 
objection. He, too, uses the expression " unsound of mind." 
u Non compos mentis" saith he, " explaineth the true sense, 
and calleth him not amens, demens, furiosus, lunaticus, fatuus, 
stultus, or the like, for non compos mentis is most sure and 
legal." And the Lunacy Act of 1845, 8 and 9 Vict. c. 100, 
in the interpretation clause, § cxiv, says, " ' Lunatic,' shall 
mean every insane person, and every person being an idiot, 
or lunatic, or of unsound mind." 

I proceed, therefore, to describe to you various patients 
who are legally unsound in mind, yet cannot be included in 
any of the classes already mentioned. And, first, let us take 
those whose malady is called by some moral, by others emo- 
tional insanity, affective insanity, and so forth. 1 do not my- 
self employ this nomenclature, but it is necessary that you 
should be familiar with it. The essential feature, whatever 
name we give it, is, that there are no delusions. 

Pinel was, I believe, the first to lay down distinctly the 
doctrine that insanity may exist without delusion. In 1802, 
he described this as manie sans delire, mania without delusion, 
and he gives a brief history of three patients thus affected. 
One of them was liberated by the revolutionary mob which 
broke open the Bieetre, but he was soon roused to fury by 
the excitement around, and was quickly led back to his cell 
by his new-found friends. After Pinel came Esquirol : to the 
partial insanity which hitherto had been called melancholia, 
he gave the name of monomania, and described two varieties 
as existing sans delire, without delusion, monomanie instinctive 
and monomanie affective or raisonnante. From his time to our 
own, all the most illustrious authorities of our profession have 
recognized this fact, and under one name or other have de- 
scribed patients whose insanity was free from delusions. I 
may cite, amongst others, the names of Hoffbauer, Georget, 



MORAL OR EMOTIONAL INSANITY. 311 

Gall, Marc, Combe, Prichard, Ray, Reil, Rush, Bucknill, D. 
Tuke, and Maudsley. 

Various names have been bestowed on this insanity, various 
divisions and classifications of it and its varieties have been 
constructed, according to the theories held as to the mind 
and its component parts. 

The mind is commonly said to be divisible into the intel- 
lect, emotions, and will. In accordance with this, Dr. Buck- 
nill speaks of intellectual, emotional, and volitional insanity, 
and Dr. Daniel Tuke points out that some such division as 
this has been adopted by many authors. Reid analyzes the 
mind, and divides it into the understanding and the will; Dr. 
Thomas Brown speaks of the intellectual states of the mind and 
the emotions ; Morel gives a triple division, the animal passions, 
the moral feelings, and the intellect; Bain's division is the in- 
tellect, emotion, and volition, while the emotional or affective 
part of the mind is by many subdivided into propensities and 
sentiments, or moral sentiments. 

Besides the division of insanity into intellectual, emotional, 
and volitional, it has been divided into intellectual or idea- 
tional, and emotional or affective, with a subdivision of the 
latter into moral alienation, or insanity of the moral senti- 
ments, and insanity affecting the propensities, or impulsive 
insanity. Here we come to the moral insanity, concerning 
which so much contention has arisen, and which is so often 
said to have been invented by doctors as an excuse for crime. 

The great teacher of the doctrine of moral insanity was Dr. 
Prichard, who, in his well-known Treatise on In- n 

7 On so-called 

sanity, published in 1835, insists strongly on this Moraiin- 

, . . . , ip i • • • sanity. 

division, and on the fact that a insanity exists some- / 
times with an apparently unimpaired state of the intellectual 
faculties." Moral insanity he defines to be "madness con- 
sisting in a morbid perversion of the natural feelings, affec- 
tions, inclinations, temper, habits, moral dispositions, and 
natural impulses, Avithout any remarkable disorder or defect 



312 MORAL OR EMOTIONAL INSANITY. 

of the intellect, or knowing and reasoning faculties, and par- 
ticularly without any insane illusion or hallucination." 

Now, I deny that the absence of the moral sense proves or 
constitutes insanity, any more than its presence proves sanity. 
It is perfectly true that it is absent in many lunatics, all no- 
tions of duty, propriety, and decency being destroyed in the 
general overthrow of the mind ; but it is also true that we 
can find perfectly sane people who, either from early educa- 
tion and habit — the habit of continual vice — and also heredi- 
tary transmission, are devoid of moral sense to an equal or 
greater degree. Probably greater wickedness is daily perpe- 
trated by sane than ever was committed by insane men and 
women ; so that when immorality makes us question a man's 
state of mind, it must be remembered that insanity, if it 
exists, is to be demonstrated by other mental symptoms and 
concomitant facts and circumstances, and not by the act of 
wickedness alone. Writers who, like M. Despine, think that 
the committal of great crimes without concern or remorse, 
indicates an absence of the ki moral sense " amounting to irre- 
sponsible defect, overlook the fact that the habit of wrong- 
doing may be acquired to such an extent that the thing done 
excites no feeling whatever. An habitual murderer, as a 
Thug or a brigand, thinks no more of taking life than does a 
veteran soldier. It is his ?&$, his everyday habit. As there 
are, according to Aristotle, spurious forms of courage, one of 
which is ip-scpta, experience, or, in other words, habit; so 
criminal and bad acts may be so habitual as to be unaccom- 
panied by any feeling of having done wrong. The gradual 
effacing of the moral sense, and gradual hardening in vice, 
have been portrayed by many a moralist; but something else 
is needed to prove the disease or deficiency of mind we look 
for in the inhabitants of an asylum. 

I cannot help thinking that the authors who have most 
strongly upheld the doctrine of a moral insanity and morbid 
perversion of the moral sentiments, have often underrated or 



MORAL OR EMOTIONAL INSANITY. old 

neglected the intellectual defect or alteration observable in 
the patients. Because no delusion has been found, it has 
been assumed that the intellect is not impaired, intellectual 
insanity and insanity with delusions being spoken of as 
synonymous. But many patients of defective intelligence 
have no delusions, as all kinds of idiots and imbeciles. Many 
of altered intelligence have not as yet reached the stage of 
delusion, and many recover from the latter, or from the stage 
at which delusions are present, yet do not recover their full 
intellectual powers, but remain semi-cured and semi-insane. 
This class is a very large one. Dr. Prichard gives as illus- 
trations of moral insanity seven cases in his own practice, 
one communicated by Dr. Symonds, and nine by Dr. Hitch. 
These are entitled " Cases of Moral Insanity and Monomania;" 
and, as they are quoted frequently in courts of law, I think 
it right to say something about them here. They are de- 
scriptions, and very valuable ones, of insane patients, not of 
varieties of insanity, and there is all the difference between 
the two. In strictness, I ought to give these cases in full, 
but time prevents. Dr. Prichard's work, however, Dr PriL . har a > s 
is to be found in most medical libraries, and I must cases - 
refer you to it. The first patient was a gentleman of high 
intellectual attainments, who married a lady no less endowed, 
and well known in the literary world. He was greatly at- 
tached to her, but extremely fearful lest it should be supposed 
that she dictated what he wrote, and he never let her know 
what he was thinking or writing about. He then acquired 
strange habits, placing everything in a certain order, whether 
in his own or other people's rooms. He would run up and 
down the garden a certain number of times, rinsing his mouth 
with water, and spitting alternately on one side and the other 
in regular succession. He employed a good deal of time in 
rolling up little pieces of writing-paper, which he used for 
cleaning his nose. It did not surprise those who were best 
acquainted with his peculiarities to hear that in a short time 



314 MORAL OR EMOTIONAL INSANITY. 

he became notoriously insane. He committed several acts of 
violence, argued vehemently in favor of suicide, and was 
shortly afterwards found drowned in a canal. Such is the 
epitome of the history of one who gradually drifted into un- 
mistakable insanity through the stages of alteration and ec- 
centricity. Even if his ideas concerning his wife, and concern- 
ing his arrangement of the articles of furniture, could not 
strictly be called delusions, it is impossible to say that in him 
was no defect of intellect. He would appear at dinner in his 
dressing-gown, apologizing for not having had time to dress, 
when he had been dressing all the morning; and he would 
go out for a walk in a winter's evening, with a lantern, " be- 
cause he had not been able to get ready earlier in the day." 

The second case is that of a patient who was at first mel- 
ancholic, timid and irresolute, suspicious of all about him, 
always changing both his studies and his residence. Soon 
he fancied himself the object of dislike to all in the house, 
and when questioned confessed that he heard whispers of 
malevolence and abhorrence. Here we have another plain 
case of a patient gradually drifting into delusions and hallu- 
cinations. 

The third patient, a maiden lady of forty-eight, after an 
attack of pneumonia, evinced alternations of depression and 
excitement for eight years, without showing any delusions 
or marked symptoms of insanity, and then broke down, had 
many delusions, " saw r people looking at her," " thought it 
was the devil who made her act so." Yet when Dr. Pricbard 
saw her, he could find no insane hallucination. She confessed 
herself, however, a that she was formerly very different." 

The fourth, a firmer, displayed no hallucination or dis- 
turbance of the intellectual faculties. Yet we hear that from 
being a man of sober and domestic habits, frugal and steady 
in his conduct, he became w r ild, excitable, thoughtless, full 
of schemes and absurd projects. He bought cattle and farm- 
ing stock of which he had no means of disposing; he bought 



MORAL OR EMOTIONAL INSANITY. 315 

a number of carriages ; called on the steward of a gentleman 
in the middle of the night to survey an estate ; and yet we 
are told that "his intellectual faculties were not disturbed." 
He was, however, placed in an asylum, and recovered. 

The fifth was a gentleman who was for many years in an 
asylum, but was released by a jury, in opposition to the 
unanimous opinion of several physicians, who all thought him 
insane. He scarcely performed any action in the same man- 
ner as other men, and some of his habits were filthy and dis- 
gusting. If a physician came near him, he recoiled with 
horror, exclaiming, "If you were to feel my pulse, you would 
be lord paramount over me for the rest of my life/' This 
individual, however, a chronic monomaniac, " has lived for 
many years on his estate, where his conduct, though eccentric 
and not that of a sane man, has been without injury to him- 
self and others." 

The sixth was a working tradesman, who, after the death 
of his wife, denied himself the necessaries of life, and lived 
in a state of starvation and filth, till removed to an asylum. 
Here he so far recovered that he was released, and married 
a servant of the asylum. She soon, however, brought him 
back to the asylum, where he remained, his derangement 
being afterwards marked by various delusions. 

The seventh, and last, was a gentleman who had had epi- 
leptic fits. He became totally changed, remained always in 
bed, was dirty, irascible, and violent. He was in a state of 
constant despondency. His friends would not place him in 
an asylum, and we are told that " the event was calamitous," 
which, I presume, means that he committed suicide. 

To say that " the reasoning faculty remains unaffected" in 
patients who commit every variety of outrageous and filthy 
act, and justify it, seems to me to involve a total misappre- 
hension of what the "reasoning faculty" means. 

But I will pass on to the cases reported to Dr. Prichard by 
others. Dr. Symonds's is that of a man who had never fully 



316 MORAL OR EMOTIONAL INSANITY. 

recovered from an attack of acute mania. He was what is 
commonly designated flighty or cracked. He advertised for 
sale property which he knew to be entailed, left his family 
without reason and without means of subsistence, while his 
letters were confused and incoherent, the expressions being 
ridiculously disproportionate to the subjects. He printed a 
pamphlet concerning his domestic history: U A more insane 
document than this I scarcely ever perused. The sentences 
were so involved and undistinguished that, 'although the 
ideas were not absolutely incongruous with each other, it was 
impossible to collect more than the general tenor of a long- 
passage." He was filthy in habits, constantly passing his 
evacuations in his bed. 

Dr. Symonds signed a certificate, though, as he says, " he 
was unable to trace any positive intellectual error," — that is, 
I take it, he could find no delusion. 

In all these cases, and in cases 1, 2, 8, and 9, reported by 
Dr. Hitch, there was plain and palpable intellectual altera- 
tion and defect, to such an extent as to make it evident that 
the patients were insane, whether their actions were moral 
or immoral ; and in many of them delusions appeared after a 
time, though in some instances the patients took a considera- 
ble period to go through the stages of alteration and aliena- 
tion, which so many pass through in a few days or weeks. 

Dr. Hitch's third is an excellent illustration of intermittent 
"dipsomania." "At times the gentleman is in habits most 
abstemious ; he never drinks anything stronger than beer, 
and frequently tastes water only for weeks together. Then 
comes on a thirst for ardent spirits, and a fondness for low 
society. He drinks in a pot-house till he can drink no more, 
or get no more to drink, falls asleep for from twenty to thirty 
hours, awakes to the horrors of his situation, and is the hum- 
blest of the meek for several weeks. In about three months 
the same thing occurs." This form deserves the name of 
moral insanity, or rather of impulsive insanity, more than 



MORAL OR EMOTIONAL INSANITY. 317 

any of the foregoing, and must be studied in connection with 
the propensity to drink. 

No. 4. This patient serves, as a good example of what may 
be called moral insanity, if the term is to be used at all. 
"He had been the inmate of several asylums, but his early 
history is not given. No delusions were ascertainable; but 
he enjoyed in a high degree the art of lying and the pleasure 
of boasting. The former was applied to the production of 
mischief and disturbance. He was an adept at stealing, and 
hoarded and secreted in his clothes and bedding articles of all 
kinds ; yet he possessed many good qualities, would be kind 
and useful in the gallery, and corrected obscene or impious 
language in others. 

"His judgment was quick and correct, he had quick per- 
ception, strong memory, and great discretion in matters of 
business. His madness appeared to me to consist in part in 
a morbid love of being noticed. He is now at large, and has 
been in the management of his affairs for three years, in 
which time he has sold an estate advantageously, and con- 
ducted his business with profit." 

The next patient also deserves to be called morally insane. 
Always of a bad temper, she gradually gave way to paroxysms 
of passion, followed by a morose and unyielding sullenness. 
A change came over her : she neglected her children, and 
abused her husband ; she smashed all the windows in her 
own house and the workhouse, and then was sent to an asy- 
lum, where she would constantly remain in bed if allowed, 
or suddenly roll on the ground and scream if questioned, or 
cry and sigh as if in the greatest distress. " As a disagreeable 
and unmanageable patient, without actual violence, she ex- 
ceeds most with whom I have met. Her mind appears 
totally unaffected as to its understanding portion, but in the 
moral part completely perverted." This case is a very good 
instance of insanity without delusions, shown, as in the last 



318 MORAL OR EMOTIONAL INSANITY. 

patient, by outrageous conduct wholly irreconcilable with 
reason. 

The same may be said of No. 6, a man who by many might 
be called bad rather than mad. "I found him one of the 
most mischievous of beings ; his constant delight was in 
creating disorder to effect what he called * fun ;' but he had 
no motive, no impression on his mind, which induced him to 
this conduct; he was merely impelled by his immediate feel- 
ings. In his state of health I found nothing wrong, except 
that he did not sleep." 

No. 7 is the case of a gentleman who suffered from cere- 
bral symptoms, and eventually died of apoplexy. He enter- 
tained deep feelings of hostility to certain persons who had 
affronted him ; but he was never insane, at least according 
to this report. 

No. 8 was a young lady distinguished in the beau monde, 
whose father's embarrassments caused her withdrawal from 
society. She became coarse and abusive, neglectful of her 
person, altogether changed in habits and feelings, hated her 
family, and said " she was dead." After three months in an 
asylum she was dismissed " much relieved." Intellectual 
change must have been observable here, as in so many of 
Dr. Prichard's cases. 

Lastly, we have the particulars of a young man whose 
defect was a morbid want of self-confidence, a fear that he 
was unequal to his business, and that he should ruin it. He 
tried to run away, and when stopped, took poison. He was 
placed in an asylum and recovered, but periodically absented 
himself from home. In time his affections were altered to- 
ward his father and family, and he became suspicious of them 
all. An elder brother, without any symptoms of madness, 
had destroyed himself. 

Here we have a well-marked instance of intermitting mel- 
ancholia, with self-depreciation amounting to delusion. 

Thus have I briefly commented on all the cases of moral 



MORAL OR EMOTIONAL INSANITY. 319 

insanity related by Dr. Prichard. That in some of them 
insanity existed without insane delusion for some time, I 
admit; but that it existed without alteration or defect of the 
intelligence, I deny. Whether we choose to call it m 

<- 1 J The morally 

emotional insanity or affective or moral, I hold that insane show 

i • t intellectual 

the intellect is also involved, that we cannot divorce defector 
the emotional and intellectual functions of the mind, 
and that this view may be upheld both on a priori and a 
posteriori grounds ; for a priori we should say that the idea- 
tional portion of the mind is so intimately joined in operation 
to the emotional — the stored ideas of the brain are so in- 
fluenced by the feelings of the moment, whether these arise 
from within or without — that the two must be sound together, 
or unsound together; so, a -posteriori, we see the insanity dis- 
played in absurd and extravagant acts, groundless and fool- 
ish likes and dislikes, or reckless squandering of health and 
property. We say of such a person, either he is mad or he 
is a fool, thereby attributing to him at once intellectual defect. 
And we shall see by and by that these acts are often com- 
mitted by persons notably deficient in intelligence, congeni- 
tally or from disease. 

It is quite certain that various patients are undoubtedly 
insane, who present none of the ordinary delusions of in- 
sanity. They may not have reached the stage of delusions, 
and they may go on to recovery without ever reaching it, or 
they may recover from the stage of delusions, and yet not 
perfectly recover, remaining in a chronic state of what Dr. 
Prichard calls moral insanity. 

We may find at any age this emotional or moral insanity 
without delusions. It is the insanity of the young. The 
second of the cases communicated to Dr. Prichard by Dr. 
Hitch, is that of a little girl aged seven, who, from being a 
quick, lively, and affectionate child, became rude, passionate, 
vulgar, and unmanageable. She was morbid in appetite, and 
would sleep on the ground rather than in a bed. She was 



320 MOEAL OR EMOTIONAL INSANITY. 

cruel to her sisters, could not apply to anything, and her 
health was much disordered. She would eat her fasces and 
drink her urine — in short, was in a complete state of mania, 
but had no fixed idea or delusion. She recovered in two 
months. 

It occurs in middle age, and, as I have said, a patient 
sometimes remains in this condition for some months, or 
even years, before he reaches the stage of delusions, or re- 
covers without ever having reached them. 

After an accident, as a blow on the head or an attack of 

epilepsy, we may perceive a change come over an 

sanity in" con- individual, insidiously gaining ground, till it is 

nection with p] a j n \} m t h e is insane, and his insanity may for a 

epilepsy. l 7 J J 

long time be of this description. I have myself 
seen two gentlemen who might have been called morally 
insane, whose disorder might be traced to an epileptic attack. 
I have already mentioned these in the "Journal of Mental 
Science," April. 18G9. One gentleman had originally received 
a concussion of the brain in a railway accident, and sub- 
sequently had an epileptic fit, and after a long interval a 
second. He was noisy, ostentatious, and boastful, irritable, 
occasionally low and hysterical. There was an extreme 
want of consecutiveness in his conversation, and this, with 
his extravagant notions and bombastic language — all quite 
foreign to him — plainly revealed his insanity ; but he had no 
positive delusions. He was in an asylum six times, yet he 
died at home, weak in mind, but sane. Twice he recovered 
after an attack of gout : although there were no delusions, 
his conversation on one occasion became perfectly incoherent, 
and his excitement arose into a state of subacute mania. It 
was very difficult to sign a certificate in his case — at any 
rate for one not previously acquainted with him — and yet no 
one who was with him for twenty-four hours could doubt his 

insanity. 

The other patient's malady also commenced with an epi- 



MORAL OR EMOTIONAL INSANITY. 321 

leptic fit, from which time he gradually became an altered 
man, and had periodical fits of drinking, though he never 
pushed this to extremes. Three years elapsed before any- 
thing occurred which justified the interference of his friends. 
He then rode on horseback to the end of Brighton chain- 
pier, assaulted the police, when bailed did not appear, and 
was then sent to an asylum. When there, he justified his 
acts in a manner markedly insane, and wrote hundreds of 
absurd letters to the same effect. He rambled both in con- 
versation and ideas. Certain officious people, who thought 
him unjustly detained, sent a solicitor to see him. He be- 
trayed no delusion whatever, but treated the whole matter 
in so frivolous a way, and wandered away from the point to 
such a degree that the lawyer pronounced him insane. He 
was subsequently discharged, and died within a year, I was 
told, of abscess of the liver. 

This form may make its appearance in old age, and con- 
stitute what Drs. Prichard and Burrows call "senile 
insanity." An old gentleman whom I knew well for insanity in 
years as the pattern of strict propriety, honor, and the aged " 
paternal affection, took in his latter days to going with loose 
women of a low class, on whom he squandered money to a 
considerable extent. Fortunately for his family his health 
gave way, and he was obliged to stay at home and be nursed, 
and his death prevented the necessity of any legal restraint. 
It would have been impossible, I think, for any medical man 
to have signed a certificate in this case at the time that he 
was running after these women, though his friends had no 
doubt that his mind was deranged. Although he had never 
shown signs of insanity till his old age, it is worthy of note 
that two, at least, of his children have evinced symptoms of 
mental derangement in middle life. In such patients this 
kind of insanity is the forerunner of senile fatuity and de- 
mentia; but some time may elapse before the mind is so de- 

21 



322 MORAL OR EMOTIONAL INSANITY. 

cayed as to warrant our giving it this name, and the term 
senile insanity would appear to be more fitting. 

When a man or woman becomes insane, the character of 
the emotion displayed depends on the general 

The emotional . . 

character of physical condition of the individual, and varies at 
different times, and the delusions will follow the 
feeling of the moment. So, when there are no delusions, and 
the insanity is manifested only in the appearance, habits, 
and acts, we shall still find that the emotion displayed will 
vary from the extreme of melancholy to the highest hilarity, 
according to the general condition of the patient, In melan- 
cholia there is almost always a premonitory stage in which no 
delusion is perceptible, and the depression may, and often does, 
last for a long time, and then pass off without any definite de- 
lusion. I say without any definite delusion ; but on close cross- 
examination we find an all-pervading feeling of gloom, or a 
feeling that everything is wrong, everything miserable and sad, 
and life itself a burden ; which is, in fact, one great and univer- 
sal delusion. This is the state of many who commit suicide — 
a state of perfect insanity, yet with so little derangement of 
ideas and intelligence that the friends shrink from inter- 
fering, and think that cheering up and change of scene are 
all that is wanted. When you hear that an individual has 
become low-spirited, even to an apparently slight extent, set 
it down that he or she is suicidal — even if the friends tell 
you to the contrary — even if the patient himself expresses a 
horror of such an act. This he will do, and an hour after- 
wards will be impelled to throw himself out of the window. 

Abnormal irascibility, or abnormal hilarity, may, no less 
than depression, characterize insanity without delusions. 
This we see illustrated by various cases narrated by Dr. 
Prichard and Dr. Hitch. Sullenness, causeless anger, with 
violent outburst of temper and corresponding acts, accom- 
pany the insanity of some, and hold a place midway between 
the extreme depression called melancholia, and the gayety 



MORAL OR EMOTIONAL INSANITY. 323 

and hilarity which others display. In fact, when a man is 
entirely changed, no matter how, you may reasonably sus- 
pect his sanity, having first thoroughly ascertained the truth 
of this change. By dint of patient and constant examination, 
you will probably come to the bottom of the whole matter, 
to the fans et origo of the change, and will find that nothing 
but insanity can account for it. Men do not suddenly change 
their nature without a cause, and when such a change takes 
place, the cause must be sought. And if you suspect insanity, 
you must examine carefully the individual and his history, 
the hisfouy quoad insanity of his parents, brothers, and sisters, 
his history as regards fits, blows on the head, or other ex- 
citing or predisposing causes of mental disorder. Then you 
must well weigh the changes alleged to have taken place in 
his temper, habits, ideas, and acts, and must hear what he 
himself has to say about his feelings and doings. You will 
probably find such an amount of irrationality, incompetence 
to argue, rambling from the point, or justification of palpably 
insane acts, as to warrant your deciding that he is of unsound 
intellect, whether the ordinary delusions of insanity appear 
or not. And although your opinion may be asked chiefly 
upon the question of sanity or insanity, yet you are Treatment and 
not to forget that the question of treatment is in- P ro » nosis - 
volved therein. Many are curable, especially those whose 
insanity has not yet reached the stage of delusions, and is of 
recent origin. Change, rest, and restraint, in or out of an 
asylum, according to circumstances, may effect a cure, and 
this you are bound to promotej Insanity following epilepsy 
or blows on the head cannot be favorably looked at as re- 
gards prognosis; but even this may be intermittent, and the 
remissions may be treated till there is at any rate temporary 
recovery, and such patients may be restored for a time to 
their homes or friends. If you meet with this form in 
patients who have recovered from severe attacks up to a 
certain point, and there have remained stationary, not being 



324 MORAL OR EMOTIONAL INSANITY. 

thoroughly restored to their right and sound mind, it may 
be possible, by judicious care and supervision, to regulate the 
lives of such in a way which will enable them to live out of 
an asylum, in the family of a friend or strange rjj and you 
may witness their perfect recovery even after a long period 
of alienation. JEhese semi-insane people, if free from mis- 
chievous or dangerous habits or impulses, have a better- 
chance of improvement out of than in an asylum. Their 
self-respect is more encouraged ; they feel that they have 
more to live for ; and the dread of going back often operates 
as a wholesome check upon their insane propensities7\ 

The mention of " moral insanity," which some tfeink to 
be a state of mind in which the moral sense is blunted or 
on the so- l° s t, leads me to say a few words on what has 
tS e o d nn- al * )een called the legal test of insanity. It has been 
sanity. Yaid down by certain of the judges, that an alleged 

criminal lunatic is responsible for his acts if he knows the 
difference between right and wrong ; and you will be asked 
in crown cases whether you think that a prisoner knows 
right from wrong. No more curious test of insanity was 
ever invented, none which more plainly shows the absolute 
ignorance of the subject prevailing amongst those who have 
no acquaintance with the insane. When Macnaughten was 
tried in 1843 for the murder of Mr. Drummond, and acquit- 
ted on the ground of insanity, the matter was made a subject 
of debate in the House of Lords, and Lord Chancellor Lynd- 
hurst stated that the law, as laid down by various judges, 
was, that if a man when he commits an offence is capable of 
distinguishing right from wrong, and is not under the in- 
fluence of such a delusion as disables him from distinguish- 
ing that he is doing a wrong act, he is answerable to the 
law. Lord Brougham, with his clear perception, saw the 
difficulty of this interpretation. u One judge," he said, a lays 
down the law that a man is responsible if he is ' capable of 
knowing right from wrong;' another says, 'if he is capable 



MORAL OR EMOTIONAL INSANITY. 325 

of distinguishing good from evil ; ' another, ' capable of know- 
ing what was proper ;' another, ' what was wicked.' He was 
not sure that the public at large ' knew right from wrong,' 
though their Lordships knew that 'distinguishing right from 
wrong' meant a knowledge that the act a person was about 
to commit was punishable by law." Certain questions were 
then put to the bench of judges by the Lords as to the in- 
terpretation of the law, and in their answers stress is laid 
upon the knowledge of right and wrong, and they talk of a 
partial delusion, whatever that may be, which does not ab- 
solve a criminal from responsibility. 

These answers are supposed, even in our own day, to be 
an authoritative exposition of the law as it affects the insane. 
So unsatisfactory are they, that one judge abides by them, 
while another does not, and nothing definite is settled. 
Some lawyers do not scruple to say that a lunatic should be 
put to death if he commits a murder, as if he were sane; 
while it has been said by a judge "that it was not merely 
for the jury to consider whether the prisoner knew right 
from wrong, but whether he was at the time he committed 
the offence deranged or not." Common sense and common 
humanity must coincide in looking upon the latter as the 
only view to be taken of the question, and it will T hoknowi- 
be for you to confine yourselves in all such cases to e(l s° of ri * ht 

J ^ and wrong. 

the simple exposition of the insanity of the indi- 
vidual, if in your opinion it exists. If you are asked if you 
think he knew right from wrong, you may answer, (I.) That 
it is not possible so to enter into and examine the internal 
consciousness of an insane man at the moment of the com- 
mission of a crime, even if we are present, as to be able to 
argue as to his knowledge of the wrong he is doing. (2.) 
That the defect of mind presumed to be present, whether in- 
sanity or imbecility, implies an absence of that perfect work- 
ing of the intellect and feelings on which knowledge neces- 
sarily depends. (3.) If we are told that many of the insane 



I 



326 MORAL OR EMOTIONAL INSANITY. 

do know right from wrong, and that they are kept in order 
in asylums by this knowledge, by fear of punishment and 
hope of reward, we answer that their knowledge of right 
and wrong is childlike and imperfect, that the system of re- 
wards and punishments is one adapted to the insane as is 
that which we apply to children, and that for violence and 
grave offences committed in an asylum no one thinks of hold- 
ing the patients responsible, or of handing them over to tlie 
law. Judges have been upheld in their notions of lunatics 
knowing right from wrong by the answers of witnesses who 
encourage and affirm it as a fact. But a person of unsound 
mind cannot be said by one of us to know right from wrong 
in any way which would render him amenable to criminal 
punishment. 



LECTURE XVI. 

Impulsive Insanity — Characterized by Criminal Acts — Explanation of 
the Impulse — Rules for Diagnosis — Other Symptoms of Insanity 
usually discoverable — Weak-minded or Imbecile Patients — Charac- 
teristics — Cases — Demented Patients — Chief Defects — Cases. 

There is another variety of insanity, or rather another 
class of insane patients, in whom, as in the last mentioned, 
no delusions are to be discovered, and whose insanity is mani- 
fested rather by what they do than what they say. This is 
impulsive or instinctive insanity, the victims of which under 
an impulse or instinct do something, commit some crime or 
act of violence, for which, being insane, they are i mpa i siV e 
not to be held responsible, but for which, were they insalllt >- 
insane, they would be punished. This form of insanity is 
considered by many to be closely allied to the last, the 
"moral insanity" of Prichard. By some it is considered as 
a variety of " emotional insanity." Dr. Maudsley describes 
it as one division of "affective insanity," "moral insanity" 
being the other. 

As we saw that a great many patients, in various states and 
stages of insanity, may be, and have been, grouped together 
by one feature common to all, viz., the absence of delusions, 
and are called " morally insane," because, there being no 
delusions, their intellect is supposed to be sound, so 

■ x m Characterized 

we shall find that a number of different lunatics by criminal 
have been said to be suffering from impulsive in- 
sanity, having this feature in common, that they committed, 
tried, or desired to commit, some act of violence, yet appeared 
to be free from everything like delusion. 

The crime itself is held to be evidence of the insanity, and 



328 IMPULSIVE INSANITY. 

is accounted for upon the theory that the person is suddenly 
and insanely impelled to commit it. We cannot be surprised 
that in courts of law "impulsive insanity without delusion" 
is regarded with great suspicion, and, together with "moral 
insanity," is looked upon by lawyers as a chimera of philan- 
thropic doctors, who' consider all grave crimes to be acts of 
madness. I have no doubt, however, that if we could suffi- 
ciently examine all the cases of so-called "impulsive insanity," 
and really ascertain the entire history and phenomena pre- 
vious and subsequent to the commission of the act, we should 
find many other signs and symptoms of insanity, and should 
be able to assign to the majority of the patients places in the 
ranks of the ordinary varieties and classes of the insane. 
And this you must endeavor to do, considering the individual 
before you rather than any particular variety or theory of 
insanity, and bringing together every fact in his life and his- 
tory — his bodily ailments, demeanor, words, and acts — which 
will prove to your own satisfaction and that of others that 
he is unsound of mind. 

I believe that the mistake made by those who describe so 
many cases as impulsive insanity is this : they have not proved 
too much, but too little. Instead of saying there is a form 
of insanity which impels patients to commit violent acts, they 
might have gone much further, and said that all insanity is 
aii insanity impulsive, all insane patients are liable to commit 
impulsive. guc j 1 ac ^ g ^ - g an i nsane patient, therefore it is 

likely that he will do such an act. We shall then have to 
prove, not that A. is afflicted with a particular kind of in- 
sanity, but that being insane in some degree or other, he 
committed the act. We have already seen, and laid it down 
as a truth, that patients may be insane, and yet have no de- 
lusions. If one of these commits a crime, we need go no 
further than to say that he, being insane, has committed an 
impulsive act of violence, his insanity being manifest from 
such and such symptoms. And these symptoms we must 



IMPULSIVE INSANITY. 329 

very carefully analyze and set forth, so that they may carry 
to others the conviction they bring to us. It may be that 
the act itself is the chief or only symptom. I think close 
observation will generally disclose others, possibly not always. 
Yet, as we pronounce patients who have no delusions to be 
insane because of their outrageous and absurd doings, totally 
inconsistent with their ordinary character and habits, so we 
may recognize insanity in an act of violence equally incon- 
sistent with the known character of the individual, or in one 
which none but a madman would commit. There may be 
such cases, but I believe them to be few. Where these crimes 
are committed, I think close and skilled observation will gen- 
erally link the act with other symptoms or causes of mental 
aberration, and as science and the study of brain-disorder ad- 
vance, we shall recognize more and more the alliance of the 
different neuroses, the affinity — nay, close relationship — of 
epilepsy and insanity, chorea and insanity, hypochondria and 
insanity, and even drunkenness and insanity. The extent 
to which drunkenness can produce irresponsibility is a prob- 
lem which jurists have never settled, and probably never 
will settle. Dipsomania may proceed from insanity caused 
by hereditary taint, or a variety of circumstances; or habitual 
drinking may itself produce dipsomania, or other forms of 
unsoundness of mind, to say nothing of delirium tremens. 
But all this is to be observed in view of each particular case. 
My present purpose rs to consider the impulsive acts of the 
insane, especially of those whose insanity, not being 

, , , . . . . . Explanation 

marked by delusions, is chiefly indicated by the act ofthe 
itself. The act, however, is plainly the outcome of 
some idea present for the moment in the mind, but present, 
possibly, only for the moment, and then so obliterated that 
the individual afterwards has lost all trace of it. As Dr. 
Maudsley says r 1 "It is no longer an idea the relations of 

1 Op. cit , p. 310. 



330 IMPULSIVE INSANITY. 

which the mind can contemplate, but a violent impulse into 
which the mind is absorbed, and which irresistibly utters 
itself in action." This being done, the feeling and idea, 
having expended themselves in action, may cease for a time, 
till the morbid process is enacted over again in the brain. 
These speculations tally with what we observe in so many 
instances. The patient having. committed the act he desired 
to commit, whether one of homicide or merely of violence and 
mischief, wakes up, so to speak ; and whether horrified at 
what he has done, or satisfied at having given vent in action 
to the craving experienced, he at any rate feels the latter no 
longer. This irresistible desire to do something — to commit 
suicide or homicide, to smash windows, or merely to strike a 
blow at something or somebody — is quite a different thing 
from acting under a delusion, under a fear of coming harm, 
a fancied command from on high, or a causeless enmity. Yet 
that such feelings are felt is admitted, certainly by all who 
make insanity their study, and by others also who are most 
removed from any predilections for the theories of lunacy 
doctors. A writer in the " Saturday Review'' 1 says: "The 
law must recognize facts, and many cases (of homicidal im- 
pulse) have occurred which can hardly be described by any 
other name." And Casper, the great Prussian medico-jurist, 
whom none will accuse of undue leniency towards alleged 
lunatics, says: "There are still other cases whose actual ex- 
istence I am all the less inclined to deny, as I myself have 
had occasion to make similar observations. These pure cases, 
that is, those in which, without the individual having labored 
under any form whatever of insanity, or having been, from 
any bodily cause, suddenly and transitorily affected by men- 
tal disturbance — those cases, therefore, in which there coex- 
isted with otherwise mental integrity, an 'inexplicable some- 
thing,' an instinctive desire to kill (Esquirol, Marc, Georget, 

1 April 25, 1863. 



IMPULSIVE INSANITY. 331 

&c), are extremely rare, or rather there are extremely few 
of these cases published; for I am convinced that such pure 
cases actually occur far more frequently than their literary 
history would seem to show." 1 That such cases exist, and 
are not merely invented by doctors to excuse crime, is suffi- 
ciently proved, first, by the observation of patients actually 
secluded or treated for this one form of insanity ; secondly, 
by the confession of those who have suffered from an impulse, 
and have either controlled it, or have come voluntarily and 
begged to be restrained, feeling unable to control themselves 
longer. In fact, there can be no doubt about the existence 
of insanity marked by such impulses. The disputed question 
is, whether the insanity is not always recognizable by symp- 
toms other than the impulsive act. 

The impulse and craving may occur in any insane person, 
in those whose insanity is patent in many ways, and in those 
where it is hid from the eyes of all who have hitherto seen 
the individual. Yet I believe we shall generally be able to 
find evidence of mental disease if we only have full Rulesf or 
opportunities of observation, and a full history of the dia s nosis - 
life and antecedents of the man and his ancestors. I say, if 
we have full and sufficient opportunity of observation. This 
may fail us, as it has failed many. In that case we had 
better say so, and decline giving an opinion, as we should do 
in any ordinary medical or surgical case where opportunity 
of examining the patient thoroughly was denied. The scandal 
which has come upon evidence given in doubtful cases of in- 
sanity has arisen from medical men giving their opinions 
after an amount of knowledge and examination of the patient 
which in no degree warranted any opinion at all. Half an 
hour's conversation with a patient may tell us very little 
about him ; it may be necessary to see him again and again ; 
to see a woman at various periods of the month ; above all, 

1 Casper's Forensic Medicine, iv, 334, Sydn. Soc. Trans. 



332 IMPULSIVE INSANITY. 

to observe a patient without his knowledge — in the night, 
at meals, in various occupations, and to see what he writes, 
if he can be got to write. We shall have to consider his 
motive for the crime — if it be a crime- — the method of its per- 
formance, and the preparations for it, and his present feelings 
with regard to it; to ascertain, so far as we can, the presence 
or absence of hereditary taint, any illnesses or peculiarities 
observable, his history as regards former attacks of insanity, 
epilepsy, blows on the head, or drunkenness ; to learn, either 
from personal inspection or reliable evidence, his conduct 
and demeanor after the committal up to the time of our ex- 
amination ; and to compare all that we see with what we 
hear. 

When patients are in asylums, and there are ample op- 
portunities of watching them, there is seldom any difficulty 
in recognizing insanity. Dr. Gray, of Utica, gives the par- 
ticulars of no less than fifty-two homicidal cases. 1 In no one 
of these was there any doubt about the insanity ; and in 
Bethlehem formerly, and now at Broadmoor, the medical 
officers can distinguish the insane from those who are sane, 
though acquitted on the ground of insanity. I am not, how- 
ever, disposed to think that it is an easy thing to diagnose 
insanity by merely visiting a prisoner awaiting trial in one 
of our prisons, and seeing him perhaps on one occasion only. 
If the examination were conducted with the care and con- 
sideration displayed in French cases, there would be less 
violent writing and dissatisfaction expressed in our journals 
when a murderer is acquitted on the ground of insanity, or 
when the sentence of the jury is reversed in the office of the 
Home Secretary. 

I think you will find, if you go to the root of the matter, 
that the act which is supposed to be committed under the 
influence of insane impulse is rarely, if ever, the first symp- 

1 American Journal of Insanity, October, 1857. 



see it in five out of six of the patients in an asylum. 
If you can get sufficient information, you will s 



IMPULSIVE INSANITY. 333 

torn of insanity or brain affection shown by the alleged 
lunatic. You may be told by friends that they have never 
seen any insanity in him ; but some people cannot 

torus of in- 
sanity usual 
discoverable. 

probably discover that he has had former attacks, 
from which he may or may not have been considered as re- 
covered. Some may have thought him well, while others 
may have always looked upon him as "odd." At any rate, 
he will have had previous symptoms ; or, possibly, he may 
have been noticed as being changed and peculiar for some 
time, short or long, prior to the committal of the act. The 
latter being the outcome and culmination of a morbid pro- 
cess which the mind has undergone, it would be extra- 
ordinary if it occurred quite suddenly in a moment of time. 
It is foreign to what we know of the pathology of disease 
generally to suppose that such sudden disorder can arise. It 
is quite possible that symptoms may be disregarded ; but 
careful inquiry will often lead to the discovery of a connected 
history of premonitory indications, even if the individual has 
never before been under restraint. It often happens that 
after a man is condemned to death this kind of inquiry is 
instituted ; a history of insanity is revealed, the sentence is 
reversed, and scandal caused by the whole proceeding. 

If a criminal has had at some time or other an attack, the 
present act may arise from a recurrence of insanity, or it may 
have been committed under the influence of a long-hidden 
delusion, a relic of the former attack, never lost, though kept 
under and concealed for years. I believe delusion to be 
common in these cases, more common than is suspected, and 
that many so-called impulsive acts are really those where 
delusions have been hidden, whose promptings the patient 
has obeyed. And no class of patients is so liable to act upon 
sudden impulse as those who have hallucinations of hearing. 
A man hears himself called some insulting name, or accused 



334 IMPULSIVE INSANITY. 

of some filthy act, and he turns round, and, deeming it to 
come from some person near him, violently assaults the 
nearest he sees. Here, however, he will justify the act, and 
we get a clue to the real state of the case ; but it may be 
thus discovered for the first time that he has had such hallu- 
cinations for years. 

- Besides the history we receive of the individual, of the 
occurrence of former insanity, epilepsy, strangeness, or alter- 
ation of character and habits, and what we learn by our 
own observation and interrogation, we shall have to take 
into consideration the character of the act, the mode of com- 
mittal, and the absence or presence of motive. This is a test 
of a more uncertain character, but one which cannot be en- 
tirely overlooked. The act may be so motiveless, that no 
one can doubt it must have been that of a madman. When 
a man murders one known to have been most dear to him, 
we may suspect insanity, and more than suspect it. It is not 
the amount of wickedness displayed in the act, but the sense- 
lessness of it that we are to regard. As I said, speaking of 
moral insanity, that there was always evidence of intellectual 
defect and alteration as well as of mere wrong-doing, so in 
the impulsive acts of the insane there is not only a wicked- 
ness, but an eccentricity, a want of motive, or a motive pal- 
pably insane, which points to intellectual and ideational 
defect or alteration, and not merely to crime, such as we 
recognize in the acts of a Greenacre or Courvoisier. 

On examining the recorded examples of homicidal impulse 
— and these are the cases to which the theory of impulsive 
insanity is chiefly applied — we shall find that in almost all 
that are reported in such detail as to be worthy of notice, 
and many are not, there was, or had been, general mental 
derangement. Of the fifty-two cases reported by Dr. Gray, 
there was manifest insanity in all. I quote from Casper: 1 

1 Op. cit., p. 333, note. 



IMPULSIVE INSANITY. 335 

" Marc has collected eight cases of so-called homicidal mania. 
There is, however, not one among them in which general 
mental disease did not indubitably exist. Cazauvielh 1 has 
collected as many as four-and-twenty French cases, among 
which there are several cases of newly-delivered women who 
felt an impulse to murder their children. This, of course, 
was no permanent monomania, but rapidly passed off, and 
only one of these falls to be considered here as coming under 
this category. All the others, without exception, refer to 
lunatics." A celebrated case, reported by Dr. Lockhart 
Kobertson in the "Journal of Mental Science," 2 was that of 
a man who, when first admitted into an asylum, had been 
insane nine months, and heard voices. Such a patient I 
should consider an incurable lunatic, and if afterwards he 
committed homicidal acts, I should set them down to the 
voices, or at any rate to his general condition. There would 
be no need to have recourse to a theory of impulsive insanity. 
And many cases so called are those of patients suffering from 
melancholia. 

Let us, however, not as witnesses in courts of law, but as 
physicians, carefully study the impulsive and un- 
reasoning acts of people of unsound mind. So com- a ^cimmon 
mon are they amongst the insane, that they attract a,n,,,, s st a11 

J ° J the insane. 

no special attention when they occur in everyday 
asylum life. We do not call it impulsive insanity when a 
lunatic all day long tries to smash the windows, or tears his 
clothes and bedding to shreds, or incessantly endeavors to set 
himself and the house on fire. Yet, perchance, he can give 
no reason for any of these things. He has no delusion in 
connection therewith. He has very few delusions. He is in 
that state of partial insanity which would be unrecognizable 
by many; and yet he is in every sense of the word a lunatic, 
and his impulsive acts are the result of his general condition. 

1 Annales d'Hygiene Publ., t. xvi, p. 121. 2 April, 1861. 



336 WEAK-MINDED PATIENTS. 

Were every impulsive act carefully recorded, we should see 
how numerous they are, and also see that the lunacy of those 
committing them is plain and undoubted. We should look 
upon them as peculiarities of lunatics, like dirty habits, 
shameless masturbation, or hallucinations and delusions. 

Besides the various patients who' are in one shape or other 
weak- insane, who are changed and altered from their for- 
mindedor mer gane ccm dition, or who commit acts inconsistent 

imbecile y 

patients, with reason and healthy mind, your opinion will be 
sought in the case of others, who, though not insane in the 
ordinary sense of the word, are, nevertheless, of unsound 
mind, and incapable of taking care of themselves and their 
affairs. When an attempt is made to bring the lunacy laws 
to bear upon them, a quibble is always raised as to their not 
being insane; but the lunacy laws have for their subject all 
" persons of unsound mind," whatever the form of unsound- 
ness may be, and this has been decided by the Court of Ap- 
peal. I shall mention two varieties of unsoundness, con- 
cerning which you may be consulted: one a weakness or im- 
becility of mind, congenital, or the result of disease in early 
life, whence the individual is through life deficient, below 
the standard of other sound people, and incapable of taking 
care of himself, his condition being a destitution of powers 
that never were possessed; the other being an enfeeblement 
and decay of a once healthy mind coming on after insanity, 
epilepsy, and brain disease of all kinds, or being the dotage 
and decline of sheer old age. The latter is much easier to 
recognize and to deal with legally than the former, the sub- 
jects of which have given rise to some of our most celebrated 
forensic contests. They may come under your notice at any 
period of their lives, but, as a rule, it will be at the time 
when they are ceasing to be boys and girls, and beginning 
to be men and women. It is found that though men in 
years, they are still children in mind; if men, men only in 
wickedness and vice, children still in intellect and in the 



WEAK-MINDED PATIENTS. 337 

sense of duty and responsibility. These weak-minded youths 
are not to be called idiots, though they are but one grade 
higher. They are weak-minded imbeciles, and the imbecility 
may be congenital, or have been brought about by convul- 
sions and fits in infancy or early life, arresting the due de- 
velopment of the brain. In a humble station, these boys 
and girls swell the ranks of criminals, and become the con- 
stant inmates of a prison, unless they are fortunate enough 
to be carried off to the more permanent haven of an asylum. 
In higher society parents are horrified at finding them in- 
dulging in vices and propensities tending to the same end, 
and seek our advice and assistance. But it is not always 
easy to give them the latter, for it is often very difficult to 
deal with such patients legally. Testing them for the va- 
rious symptoms of insanity, we shall find that there is very 
little to warrant our signing a certificate for their care and 
detention. Possibly they may be approaching the age of 
twenty-one, and the question will arise whether they are or 
are not fit to take care of property? Or they may be uncon- 
trollable by any government, home or tutorial, and even at 
an early age are addicted to practices which entail the inter- 
ference and punishment of the law. These children have no 
delusions ; none need be looked for, for none will be found. 
They are not changed in habits and demeanor. They are 
now what they always have been — stubborn, eccentric, 
spiteful, mischievous, often horribly cruel, vain, perfectly de- 
void of truth, incapable of being taught, but picking up in a 
desultory way many scraps of information, and holding these 
with a most tenacious memory ; given, perhaps, to some one 
amusement or hobby, and doing this for a time fairly well, 
but irregular and restless, fond of change and novelty, and 
wholly unable to settle down assiduously and constantly to 
one pursuit. The parents, if gentlefolks, seek the physician's 
assistance; but, as I have just said, this is often hard to af- 
ford. How are we to test these patients? Impressed with the 

22 



338 WEAK-MINDED PATIENTS. 

symptoms of dementia, we try their memory, and find it ex- 
cellent. We watch them at dinner and in society, and we 
find they conduct themselves with perfect propriety. We 
examine them as to the value of money, and they evince a 
keen appreciation of the amount of amusement to be got out 
of half a crown or half a sovereign. On the common topics of 
life they will converse readily and accurately, read the mis- 
cellaneous news of the journals, and recollect what they have 
read. And they may excuse their ignorance of other mat- 
ters on the ground of their education having been neglected, 
or, if we ask them concerning their property and affairs, may 
say that these have always been managed for them, and that 
they have had no occasion to attend to them. In short, a 
formal examination of such people may tell us nothing. 
They are on their guard and good behavior, and if we tax 
them with their sins, they confess them, allow it was wrong, 
and promise amendment. Only those who live with, and 
have opportunities of observing them at all times, with and 
without their knowledge, can give a just and complete ac- 
count of their mental state. If we ourselves have no such 
opportunity, we must receive the statement of those who 
have, and test it, so far as we can, by our own observation. 
Possibly we may not be able to pronounce an opinion. We 
must at any rate be careful how we give a negative opinion, 
based on our imperfect information, in opposition to that of 
others who have had ampler opportunities of coming to a 
sound conclusion. 

The chief characteristics of these patients are a childish- 
character- ness m mind, showing itself in an inability to learn, 
istics. think, or reason like others of the same age and 

social standing; frequently, but not always, a tendency to 
low and depraved habits, to vice of a kind not to be looked 
for at such an age, and an unnatural hatred and malice ex- 
hibited to parents, brothers, or sisters. Great stress has been 
laid on this moral depravity, and theories of moral insanity 



WEAK-MINDED PATIENTS. 339 

have been founded upon it. Without discussing the ques- 
tion of an innate moral sense, I would say that, in conjunc- 
tion with the depravity, we shall, I feel confident, find in 
such patients a low and imperfectly-developed intellect, in- 
capable, because of its feebleness and childishness, of finding 
pleasure in anything but the brutish and sensual enjoyments 
of the body. It may be able to lay up the facts of every-day 
life and experience — may know how much pleasure a shil- 
ling may buy, but of knowledge to be derived from reasoning, 
judgment, and reflection, it possesses none. But it is most 
difficult to say this man is imbecile, and that one is not — to 
set up a standard, not of insanity, but of sufficiency of mind. 
It was said by Sir Hugh Cairns in the Windham case that — 
"In a case of imbecilitv, where there is either no mind at 
all, or next to none, the task of coming to a right and just 
decision is comparatively easy. It is impossible for a man 
who is said to have only a limited amount of mind, or none 
at all, to assume at any moment or for any purpose a greater 
amount of mind than he really possesses. If the mind is not 
there, or only there in a certain small and limited quantity, 
no desire on the part of the individual to show a greater 
amount of mind, or to assume the appearance of a greater 
amount of mind, can supply him with that which nature has 
denied him. Hence, when a man is charged with imbecility, 
if it can be shown that for a considerable time, and in various 
situations, he has acted like a natural being, any acts of folly 
which might be alleged against him should be carefully, de- 
liberately, and keenly investigated, because at first sight it is 
next to impossible that a man can at certain times assume a 
mind and intelligence which are wholly absent." These re- 
marks show the difficulty we have to pronounce upon the 
absence of mind — in fact, to prove a negative — and not the 
entire absence, but the absence of a particular amount and 
measure of mind. As Sir Hugh Cairns suggested, a man's 
acts of sanity must be weighed against his acts of folly. In 



340 WEAK-MINDED PATIENTS. 

all these cases acts are of far more importance than words ; 
for there being no delusions, and the ideas of these weak and 
uneducated persons being but scanty, we are not likely to 
detect much that is erroneous or extraordinary in what they 
say. By what they do, however, or would like to do, they 
betray their imbecility and incapacity for taking care of 
themselves. They are not uncommon, and you will not be 
long in practice without meeting with some examples. The 
particulars of one or two I have already recorded in the 
" Journal of Mental Science," 1 and will briefly give here. 
One was a youth, well born, with every advantage of educa- 
tion which wealth could give. When I first knew him 
he was between fifteen and sixteen years of age. As a 
child he was looked upon as weak-minded, and though he 
had been at various schools and tutors, education had stood 
still, and his handwriting, spelling, and letter-writing, would 
have been bad for a boy of eight. When I first saw him he 
was living with a man who was to him virtually an attend- 
ant, whom he hated no less than feared. Thence he was 
sent to a farmer's to learn farming, but one evening he 
assaulted the maid, took out a horse from the stable, rode off 
to the nearest town, and took up his quarters at a small 
public house. Thence, brought back to his first quarters, he 
escaped to Brighton, pawning all he could carry off. He 
was placed in lodgings with various attendants, with each of 
whom he got on very well for a time, during which he was 
on his good behavior; then he had an outburst of passion 
because he was not allowed to do as he liked, and would do 
nothing right till the attendant was changed. His tastes 
were low, his pleasures either depraved or childish ; yet he 
was not utterly bad: he valued the good opinion of his 
father and mother and my own, but this he was constantly 
forfeiting, for which he was sorry, but, as he said, "he could 

1 April, 1869. 



WEAK-MINDED PATIENTS. 341 

not help it." Next he went to a medical man's house, and 
behaved for a month or two so well that the character he 
took with him was thought to be unjustly exaggerated. But 
he broke down and behaved outrageously, and then an 
attempt was made to place him in an asylum. However, 
the certifying medical gentleman stated nothing in the cer- 
tificate but acts of depravity, and the Commissioners in 
Lunacy refused to receive them, so he was released. Since 
then he twice enlisted in the army, but was bought out again 
by his friends. On the second occasion, however, he was in 
the regiment for some months, kept clear of scrapes, and had 
a good character from his sergeant, but he was looked upon 
as " not right." He then took to race-courses and set up as 
a betting man, and after this threatened his father's life, was 
brought before a magistrate, and locked up. There can be 
no doubt that this youth will degenerate into one of the 
regular criminal class, unless he is fortunate enough to get 
to an asylum. Here he would at times beg to be allowed to 
go, at others he would defy any one to send him. 

Now, of those who by constant intercourse with this youth 
had the best opportunity of rightly judging of his mental 
state, no one thought him of sound mind. And yet his un- 
soundness was not at once manifest, nor was it easy to re- 
duce it to a short verbal description. Probably, on no one 
given day could any medical man have seen sufficient to 
enable him to sign a valid certificate, yet he was imbecile 
and childish. His attainments and mental calibre were those 
of a child of eight or nine ; and although in certain strata of 
society education marks little, yet in the highest ranks an 
incapacity to receive even the elements of education is sig- 
nificant. He would repeat the same question over and over 
again like a demented patient. This, again, though not 
much in itself, is a common symptom of the loss of memory 
or attention which characterizes the feeble-minded. He dis- 
played that love of change, that periodicity of outbreak and 



342 WEAK-MINDED PATIENTS. 

restlessness, so often met with. He could go on quietly and 
well for a certain time, but then he found a vent, either in 
passionate quarrelling, drinking, or riotous behavior of one 
kind or other. And this I verily believe he could not con- 
trol or help. He had a good memory and a certain sharp- 
ness about details, which are not uncommon, even among 
idiots. He knew the times of all the omnibuses on the road, 
and could give the times of trains according to " Bradshaw " 
by the column. He was sharp enough in calculations of 
pence and shillings, but he would have been perfectly in- 
capable of taking care of an estate, or any large property. 
His head was very small, his whole development of brain 
and mind in defect. He had no powers of reasoning, and he 
lived, in fact, the life of an animal, only caring to gratify his 
appetites. 

Such another was a youth who was possessed of some few 
hundred pounds — or would have been in a few months, as he 
was approaching the age of twenty-one. This his friends 
wished to protect, and applied to the Lords Justices for an 
order. 1 He had run the same course as the former, but in- 
stead of being sent to learn farming, he had been sent to sea. 
He knew, however, nothing about a ship, though he had twice 
sailed to Australia. He had run away while out there, and 
ran away, in fact, wherever he was. He could tell me noth- 
ing about what he had seen, neither could he tell the name 
of the street in London in which he was living. He was 
defective both in attention and in judgment. He had no 
idea of doing anything with his money when he got it, but 
thought he should set up a dog-cart. He seemed to be en- 
tirely ignorant of everything connected with property, secu- 
rities, and investments. He was plainly unfit to have the 
care of property, and the Lords Justices made the order 
accordingly. 

1 Vide Lect. XIX. 



WEAK-MINDED PATIENTS. 343 

One of these doubtful cases was that of a girl whose father's 
family was saturated with insanity. She had quarrelled with 
her sisters, her mother, and innumerable governesses. She 
had fits of obstinacy, during which she refused to do any- 
thing required of her. She was peculiar, would dress fan- 
tastically, would cut off the toes of her stockings, and do 
other odd things which were not mere child's mischief. Yain 
and conceited, she spoke of her mother and her sisters as 
poor unenlightened creatures, affected much knowledge, and 
pretended to read deep books ; yet she was intellectually 
deficient and backward for her age. She spelt badly, and 
could not be taught. When walking with her mother she 
would signal to strange men in the street, and talk of her 
wish to get married. She was such an extraordinary liar 
that it was a work of time to realize the fact that all her 
stories were lies. She went to Scotland, and I lost sight of 
her, but I have no doubt that her unsoundness of mind will 
become more and more patent. 

Your opinion will be asked with regard to the training of 
these imbecile children, as well as the restraint 

it i "\T7-i i i Treatment. 

by legal means. When all tutors and governesses 
have been exhausted, the friends will seek medical aid, find- 
ing their own efforts more productive of harm than good. 
Parents, as a rule, have but little influence, neither are they 
in general judicious in their conduct towards them. You 
must recollect that such unsoundness is for the most part 
inherited, and }~ou will detect peculiarities in the father or 
mother — great irritability, intemperance, or weakness of 
character. Fathers are often very harsh and severe to these 
children ; and mothers, on the other hand, screen their 
faults, and so encourage vicious propensities. Those of you 
who see them from childhood may do much by counsel and 
advice to promote their welfare and improvement. You will 
rescue them from blows, imprisonment, and undue punish- 
ment — from the irritation of angry parents, and the indul- 



344 DEMENTED PATIENTS. 

gence of foolish ones : above all, from being handed over 
entirely to the mercy of servants and attendants. Sooner or 
later these boys and girls are found such a pest at home that 
they are sent away, first of all to school. But few schools 
can keep them ; and then the boys go to a tutor, the girls to 
a family. Here everything depends on the character of the 
individual who controls them. It requires a high order of 
mind, together with unwearied assiduity and vigilance, to 
train with success these blighted waifs of humanity. Yet it 
may sometimes be done. The great problem is to find out 
something, some walk or occupation, for which the child is 
fitted. Many are capable of doing something. We are deal- 
ing with a defective mind, a mind incapable of following the 
pursuits of those in the same sphere of life — incapable of 
commanding a regiment or a ship — incapable of studying 
for a learned profession ; but capable, it may be, of executing 
the mechanical work of doing such things as we see done at 
Earlswood; or pleased at being occupied about animals — 
horses, or dogs — and, under judicious and kindly surveil- 
lance, capable of a habit of self-control and regularity. Par- 
ents may shrink from having their son put to a trade ; many 
would far rather shut up in an asylum sons and daughters 
who are likely to disgrace the family. But I need not use 
argument to prove that it is better to bring up boys or 
girls in a humble occupation, in w T hich they may cultivate 
self-restraint and self-respect, than to apply restraint by force 
of law. 

I now come to the second class, patients whose minds have 
Demented fallen into decay from disease of the brain of some 
patients. \^{ X1 ^ or f r0 m old age. There is little difficulty in 
recognizing this condition. I only mention it because you 
are to recollect that they come under the provisions of the 
Lunacy Acts, just as maniacs or any other insane persons; 
and if sent away from home, they must be placed under cer- 
tificates of lunacy, if they cannot be pronounced able to take 



DEMENTED PATIENTS. 345 

care of themselves and their affairs. I have known the men- 
tal condition of these individuals disputed in a court of law 
under such circumstances as I have alluded to ; but, as a rule, 
there is not much contention about it during their lives. 
Their defect is palpable, irremediable, and ever increases till 
death; but after that, a contest often arises over their wills, 
and we hear evidence to prove, on the one hand, that the 
testator was a drivelling dotard, on the other that he was like 
other people — so differently do witnesses regard the sayings 
and doings of other men. 

The most constant defect met with among these patients 
is loss of memory, varying at different times and in Defects to be 
degree. Chiefly, the individual forgets recent occur- noticed - 
rences, retaining a vivid remembrance of the days of his 
youth. He may forget the names of those most near to him, 
the name of the place in which he is residing, and may be 
unable to give any accurate information respecting his busi- 
ness and affairs. Now, to be of disposing mind — to be capa- 
ble of making a will — a man must be, as the lawyers say, of 
"sound mind, memory, and understanding." It is clear that 
memory is essential to sanity, so clear that I need not dwell 
upon it. But the degree of failure of memory may vary 
much. Some people have naturally bad memories; some 
have great difficulty in recollecting names ; others forget 
dates ; and you will have to consider, in view of each indi- 
vidual case, whether the failure of memory is to such an ex 
tent as to separate the patient from all who can be called 
sound and sane in mind, and render him palpably unable to 
take care of himself and his affairs. You will ask, could 
such a one shift for himself, take a lodging or house, come 
and go unattended, and pay his accounts ? If he could not, 
he must be allowed to be unsound of mind. It is more diffi- 
cult, however, to come to a conclusion in respect of a lady. 
For ladies frequently do not take care of themselves or their 
affairs at any time of their lives, nor do they pretend or claim 



346 DEMENTED PATIENTS. 

to do so. Many could not who are yet of sound mind, and 
able to make a will. You must take this into account when 
you are examining ladies with a view to testing their mental 
strength or weakness. I lately examined a lady who had 
been in former years an inmate of an asylum, and who since 
then had lived as a boarder in a family. She met all ques- 
tions as to her affairs, by saying that she left all that to her 
man of business, and on common topics she talked well 
enough. There was no loss of memory, and though I do 
not suppose she could have lived entirely by herself, yet 
there was nothing to make me certify that she was legally 
of unsound mind. It was just a case for the guardianship of 
trustees, who already existed. Failure of memory you will 
look for in these cases of dementia, and will estimate it ac- 
cording to its gravity ; and you will often find yourself assisted 
by other symptoms, such as dirty habits and tricks, wetting 
or fouling clothes and bedding, or conversations devoid of 
delicacy or decency. 

Two gentlemen I saw in this condition, who, up to the 
time of inquiries made by the Commissioners in 

Cases. . . 

Lunacy, had been living under care and guardianship 
away from their friends, who, nevertheless, did not consider 
them insane, because they had no delusions. 

One of them was in an advanced stage of dementia. His 
memory was gone. He did not know the name of the pro- 
prietor of the house, nor that of his daughter, nor, in fact, 
any name but his own. He did not recollect how long he 
had been there, whether months or years. By night he had 
forgotten that he had seen his daughter in the morning, 
though her visits were of rare occurrence. He kept repeating 
over and over again the same sentence, without reason and 
without being addressed. His habits and person were filthy 
beyond description, as was the miserable room where I found 
him lying on bedding that was literally a dung-heap, yet in 
which he remained voluntarily and contentedly. This gen- 



DEMENTED PATIENTS. 347 

tleman's condition was that of dementia following on hemi- 
plegic attacks. He was not hemiplegic, however, when I saw 
him, but, with slow and shuffling step, could walk some miles 
in a day. The state of his person sufficiently indicated that 
of his mind, which was altogether deficient and gone ; yet 
lawyers were found to argue that, because he had no delu- 
sions, he was not " insane." 

The other had been insane, and frequently an inmate of 
asylums. His insanity was, as I understood, the result of 
drink, and it had terminated in dementia. His memory was 
gone ; he did not recollect that he had placed all his affairs 
in the hands of trustees ; but told me that he had a balance 
at his banker's, and that he drew cheques, which his ser- 
vant got cashed, when he had done nothing of the kind for 
years. He, too, would repeat the same sentence and ask the 
same question over and over again ; and was dirty in habits ; 
though not neglected like the former patient. 

Now, you will have no difficulty in appreciating the condi- 
tion of such people. They cannot conceal their defects, 
especially this great loss of memory ; but the opinion you are 
to give concerning them may have reference to one of several 
things. You may be consulted as to the power of such a 
patient to make a will or execute a legal instrument, as the 
sale of an estate, and you may be requested to act as one of 
the witnesses in such a matter. You may be asked to sign 
a certificate of lunacy, or give an affidavit and evidence for a 
commission in lunacy; or you may have to advise as to the 
chances of amelioration or recovery. And to take the last 
of these, we may look as a rule upon chronic dementia as 
hopeless and incurable. But we must inquire into the his- 
tory ; for it occasionally happens that what at first sight ap- 
pears very like incurable dementia passes off in course of 
time. I am not now alluding to what I have already de- 
scribed as "acute dementia," which is a variety of acute 
insanity ; but we sometimes find that after an apoplectic or 



348 DEMENTED PATIENTS. 

epileptic attack, or even after an acute disease such as fever, 
there is for weeks or months great weakness of intellect, with 
loss of memory, and complete inability to transact business, 
and jet the patient may perfectly recover and be himself 
again. Time, therefore, is our great guide in prognosis here, 
as in other mental affections ; where the dementia is beyond 
question chronic, it is not likely that the individual will again 
be able to take care of himself or his affairs. There may be 
also great improvement in the mental and bodily condition 
of a demented patient, even when recovery is out of the ques- 
tion. Those who are much neglected, and are to be found 
occasionally in an abject state of filth and destitution in 
private houses, are susceptible of much amelioration if prop- 
erly tended and fed. You will recollect that certificates will 
be required if they are not under the care of their relations, 
whether they are in an asylum or in a private house. As 
regards their competency to make a will or transact business, 
you will, of course, carefully weigh the extent of the imbe- 
cility, and the importance of that which they are about to 
do. You may allow a patient to sign a receipt for money, 
whom you might think unequal to transact any involved or 
lengthy business. Let it be your rule, generally, not to sanc- 
tion with your presence, or attesting signature, the execution 
of any document by a person whose rnind is in any way 
affected, for you may find yourselves involved in troublesome 
legal contests. 



LECTURE XVII. 

Terminations of Insanity — Liability of Recurrence — Recovery often 
Imperfect — How recognizable — Release of Dangerous Patients to be 
refused — Concealed Insanity— A Trial to be advised — Recurring In- 
sanity — Lucid Intervals — Recoveries numerous — Chance of Life — 
Causes of Death — Diagnosis of Bodily Disease — Care of the Chronic 
Insane. 

I propose, in the present lecture, to consider briefly the 
terminations of an attack of insanity ; for you will be called 
upon in practice to pronounce an opinion upon various points 
in the after-history of one who has at any time so suffered, 
whether he has recovered or not. He may recover from an 
acute attack, only to continue in a state of chronic insanity. 
In this condition is his life likely to be of long or short dura- 
tion? If he recover altogether, is he liable to a recurrence, 
and what is his chance in a second or third attack ? If he 
were to insure his life after having recovered from one attack, 
what is the value of his life? To answer these questions is 
no easjr matter. We must have recourse to those asylums 
whose numbers are large, otherwise our deductions must be 
formed upon very insufficient data; but it is very difficult to 
follow the fortunes of all those who are discharged from a 
large asylum, and to speak with accuracy of the subsequent 
history of their life and death. Dr. Thurnam, however, while 
at the York Retreat — the asylum belonging to the Society of 
Friends — had singular facilities for tracing the subsequent 
history of the patients discharged thence; and, among many 
most interesting tables of statistics, he gives one, which I 
will quote : 



350 



THE TERMINATIONS OF INSANITY. 



" Table showing the history of two hundred and forty-four 
persons who died at, or after discharge from, the York Re- 
treat, from 1796 to 1840, with the number who died during, 
and after recovery from, the first or subsequent attack of 
mental disorder." 



Cases followed 
through life. 


Died Insane 

during the 

First Attack. 


Recovered from the First Attack. 


Total. 


Recovery 
Permanent. 
Died Sane. 


Had subsequent Attacks. 


Died 

Sane. 


Died 
Insane. 


Total. 


Males, 113 
Females, 131 


55 

58 


58 

73 


21 
24 


.6 
14 


31 

35 


37 

49 


Total, 244 


113 


131 


45 


20 


66 


86 



Now although, as Dr. Thurnam says, certain deductions 
T . v .,., must be made from the picture which this table 

Liability to L 

subsequent exhibits, it must still be allowed to be a melancholy 
one. 244 persons of the middle ranks of life, not 
poor and destitute, but well-to-do people, as the Friends 
generally are, become insane, and of these only 131, or 53.6 
per cent., recover from the first attack ; the rest never re- 
cover, and die insane. But looking at the after-history of 
the 131, we find that only 45, or 18.4 per cent, of the whole, 
remain permanently sane. The rest are again insane, once 
or oftener, and of these only 20 die sane. " In round num- 
bers, then, of ten persons attacked by insanity, five recover, 
and Hwe die, sooner or later, during the attack. Of the five 
w T ho recover, not more than two remain well during the rest 
of their lives, the other three sustain subsequent attacks, 
during which at least two of them die. "B ut although the 
picture is thus an unfavorable one, it is very far from justify- 
ing the popular prejudice that insanity is virtually an in- 
curable disease ; and the view which it presents is much 
modified by the long intervals which often occur between 
the attacks, 1 during which intervals of mental health (in 



THE TERMINATIONS OF INSANITY. 351 

many cases of from ten to twenty years' duration) the indi- 
vidual has lived in all the enjoyments of social life/' 

Although the statistics derived from my own experience 
would be too scanty to be worth anything, they would, I 
believe, fully bear out the assertion of Dr. Thurnam. LIf we 
could carefully watch every case of insanity from its com- 
mencement, I fear we should see that a less number than 53 
per cent, recover from the first attack, so great is the pro- 
portion of those who are incurable from the first,\or who, 
from the prejudices of friends, are not subjected to treatment 
till the chance of cure is gone ; and if by dint of proper treat- 
ment the above percentage recover, they only recover again 
to become insane in a large proportion. Although it would 
not only be uncharitable, but unscientific and at variance 
with facts, to look on all who have once been insane as 
lunatics for the rest of their lives, it must yet be confessed 
that popular prejudice receives considerable support from 
these statistics, and (men may look with reasonable suspicion 
on former inmates of an asylum, when they hear that of 
those said to have recovered only two out of five remain per- 
manently welLj We may fairly say, that ^vhen a man or a 
woman has once been insane, no one can tell when he or she 
may not again become so. ( The changes and chances of life 
are not to be guarded against. With the utmost caution a 
former patient may be suddenly exposed to the shock of 
some horrible sight or accident, to the loss of one most dear, 
or to reverses of fortune. And, therefore, if you are con- 
sulted about the propriety of such a person contracting mar- 
riage, or entering into a partnership or any engagement 
whatever, recollect that he is exposed to extra risk on 
account of what he has already gone through, and that his 
previous recovery does not insure his subsequent immunity 
or subsequent recovery from future attacks. I have said 
already that a woman who has at any time been insane 
ought to be preserved from the peril of childbirth for her 



352 THE TERMINATIONS OF INSANITY. 

own sake, to say nothing of the danger incurred by her chil- 
dren. A man is, of course, exposed to less personal risk by 
marriage : probably to him the married state is rather an 
advantage than otherwise. He is thereby induced to lead a 
regular life, and has at hand a constant companion and 
nurse, who is aware if his nights are sleepless, or if he has 
peculiar habits or ideas, such as often escape for a length of 
time the observation of friends or more distant relatives. 
But we are not to forget that the man may become insane 
again, nay, will most likely be so, that his wife will have all 
the anxiety, and be exposed to the dangers consequent upon 
such an event, and that children may inherit allied maladies, 
or the disorder itself in its many forms. 

When we closely examine the state of those said to have 
Recovery recovered, we may find that the recovery is suffi- 
frequentiy c i en t perhaps to warrant their being discharged 
from the asylum, and to be called cured by their 
friends, but that ever afterwards they are odd and eccentric, 
or easily upset by the merest trifles, or they periodically 
break out into violence or an acute state, which ought rather 
to be called an exacerbation of their habitual condition than 
a fresh attack of insanity. I had formerly under my care 
on various occasions an old farmer whose first attack was, I 
believe, at the age of seventeen, his last was when he was 
upwards of eighty, and in the interval he had been in an 
asylum nearly thirty times. He used to stay some months, 
his excitement then passed away, and he returned home to 
be his own master. He was discharged in the books as " re- 
covered," but he had not really regained sound mind — he 
had only recovered from an acute attack of excitement ; he 
did not even lose his delusions, for he had, if I am not mis- 
taken, a persistent delusion throughout his whole life that 
he was married to a noble lady. Dr. Sankey, in his Lec- 
tures, lays great stress on these half-recovered cases. He 
believes that recovery from the first attack is not so com- 



THE TERMINATIONS OF INSANITY. 353 

mon as might be thought from statistics; "that, therefore, 
what appears to be, and is usually called, a second attack, 
is no such thing. I believe that there is a remnant of the 
old disease, a smouldering of the morbid processes still left in 
these cases, though often very difficult of detection. . . . 
This under-current of disease is, as I have said, more marked 
or less marked. In those cases in which it is obvious, and 
constantly so, the patient would be simply called a chronic 
lunatic, or he would have perhaps that form of chronic in- 
sanity to which the title folie circulaire has been given ; but 
in the class in which the mental symptoms are exaggerated 
at distant periods, and a great degree of intellectual integ- 
rity remains in the interval, the disease would be called by 
a host of names, according to the different views of different 
authors. For my own part, I would include all these cases 
under the one term of recurrent mania, or recurrent insan- 

Hi/-" 1 

Dr. Sankey goes on further to say, that he has examined 

the reports of a great many persons accused of acts of vio- 
lence, and he found in every case that the violent deed was 
not the first insane act of the lunatic. When we hear of 
cases of impulsive insanity, and it is stated that no insane 
symptoms had ever been observed before the commission of 
the act, he is of opinion that such statements emanate from 
those who are not capable of making a correct diagnosis, or 
who ignore the fact that there has been a former attack of 
insanity, or suppose perfect recovery to have taken place, 
and the subsequent attack to be altogether a fresh and dis- 
tinct event. 

How are you to know when a patient is recovered ? We 
have the same difficulty in deciding this as is so „ . 

^ ° How is re- 

often experienced in determining in the first in- cover? to he 

, , ... recognized? 

stance, whether a man is, or is not, insane. 



1 Lectures on Mental Diseases, p. 94. 
23 



354 THE TERMINATIONS OF INSANITY. 

We find patient's friends, lawyers, and others not versed in 
the study of mental diseases, contending that a man is cured 
when the chief symptoms of acute insanity have abated, and 
he can talk rationally on some points — when, in short, they 
are unable to see insanity plainly depicted in his words and 
actions. And then in this semi-recovered condition they de- 
mand his release. He may have only got rid of half his de- 
lusions, or may have learned to conceal them, or may have 
lost them, and yet be in a weak and unstable nervous state, 
requiring repose and a considerable period of convalescence ; 
yet the demand for his release may be loud and persistent, 
and in withstanding it. you will meet with many difficulties. 
More especially will this be the case with private patients. 
The friends of paupers care less for their releasePTn public 
asylums they are carefully kept at the expense of the county, 
but the friends of private patients, thinking that those who 
have charge of them have an interest in their detention, set 
up their own opinion concerning the question of recovery in 
opposition to the interested, as they suppose, advice of the 
medical attendant. If patients are ever discharged too early 
from public asylums, it is probably due to the overcrowded 
state. There can be no question that they are frequently re- 
leased too soon from private establishments on account of the 
importunities of friends, and the unwillingness of proprietors 
to submit to the insinuations and misrepresentations of the 
latter. / When there is brought against a medical man the 
accusation that he is detaining a sane man for the pecuniary 
advantage to be gained thereby, i.t requires considerable 
moral courage to withstand such pressure. Yet in many 
cases it is our duty to do so, and by dint of temperate argu- 
ments, and the assistance of collateral friends and advisers, 
to prevent the disastrous result which may follow the release 
of a half-cured patient. 

Such a state of things is contemplated by the legislature, 



Release of 



THE TERMINATIONS OF INSANITY. 355 

and provided for. If a lunatic's friends determine to release 
him from an asylum, the medical attendant may, 
if he considers him dangerous, refuse to liberate %mg< 
him. In the Lunacy Act, 1845, 8 & 9 Yict. c. 100, ***?*"?* 

*t ' ' j be refused. 

§ 75, we read : " Be it enacted, that no patient shall 
be removed, under any of the powers hereinbefore contained, 
from any licensed house or any hospital, if the physician, 
surgeon, or apothecary, by whom the same shall be kept, or 
shall be the regular medical attendant thereof, shall by writ- 
ing under his hand certify that in his opinion such patient is 
dangerous and unfit to be at large, together with the grounds 
on which such opinion is founded, unless the commissioners 
visiting such house, or the visitors of such house, shall, after 
such certificate shall have been produced to them r give their 
consent in writing that such patient shall be discharged or 
removed ; provided that nothing herein contained shall pre- 
vent any patient from being transferred from any licensed, 
house, or any hospital, to any other licensed house or any 
other hospital, or to any asylum; but in such case every such, 
patient shall be placed under the control of an attendant 
belonging to the licensed house, hospital, or asylum to or 
from which he shall be about to be removed for the purpose 
of such removal, and shall remain under such control until 
such time as such removal shall be duly effected." 

Here, then, you see that power is given to prevent the 
release of dangerous patients. We cannot, however, prevent 
their being transferred to another asylum ; but when the 
friends apply to the commissioners for an " order of transfer,." 
the latter always write to the medical attendant, and require 
from him a certificate that the patient is capable of being 
removed with safety ; and without such certificate no "order 
of transfer" is granted. It often happens that removal to an- 
other asylum is of great service to a patient whom we cannot 
release : great soreness may have arisen between him and 
those who have had the control of him, and removal and 



356 THE TERMINATIONS OF INSANITY. 

change of scene and attendants may effect a cure which 
would not otherwise have come to pass. 

But, to revert to our question, how are you to know when 
a patient is recovered, and may fitly be trusted with the 
management of himself and his affairs ? As an alteration in 
the general bearing, demeanor, and habits of a man is the 
surest sign of mental disorder, so an alteration from the state 
in which we receive him as a patient, is an indication of 
amelioration or recovery. But our difficulty in pronouncing 
an opinion as to perfect recovery is often great when we have 
never known the patient in his previous sane condition. 
You, who will become not asylum doctors, but family ad- 
visers, will first see a man sane, then insane; and if, at the 
termination of an attack of insanity, you are called to examine 
him, you may be able to say at once that he is, or is not, 
himself, and may give most valuable assistance to the asylum 
doctor, who may erroneously suppose that he is not, or is, 
cured. Friends are so apt to be biassed, and near relatives 
are so often themselves crotchety and peculiar, that we hail 
with satisfaction the information to be gained from others. 
Friends are frequently over-eager to release the lunatic be- 
cause of his displeasure, or over-fearful of setting him at 
liberty lest he relapse. Alteration in character and manner 
will be a test of recovery when the patient is greatly im- 
proved, and has got rid of delusions, when, in fact, it might 
be very difficult to sign a certificate for him. With all this 
amendment, his manner may not be natural. He may be 
unduly depressed, excitable, or irritable. His friends will 
ascribe this to the detention, if they wish his release, and 
will tell you they are quite sure that it is thus produced, and 
that it will pass away when the cause is removed. But it is 
a fact within my experience, that we do not see this depres- 
sion or excitement in those who are perfectly cured, and 
know that their stay in the asylum is only a question of 
weeks or days. Friends imagine that a patient cannot be 



THE TERMINATIONS OF INSANITY. 357 

aware that he is in an asylum without its having a prejudi- 
cial effect; but this is not so, for he will go on to perfect 
recovery in it in spite of their fears and remonstrances. 
Sometimes it happens that, when a patient is progressing 
favorably to recovery, and is not half but wholly cured, his 
friends are much more anxious for his release than he is him- 
self, and in this case his wishes and opinion ought to be con- 
sulted rather than theirs. 

We shall have to base our diagnosis of recovery upon what 
we hear from the patient himself concerning his illness, its 
cause, and symptoms, such as acts, delusions, or hallucina- 
tions ; upon what we see of him, his forsaking or continuing 
eccentric habits, peculiarities of dress or demeanor; on what 
we hear of him from attendants and others, when he is out 
of our observation ; and on what we are told by relatives, 
friends, or medical attendants. And then we shall have to 
decide whether a condition of apparent recovery is a genuine 
and perfect recovery, or merely an interval between attacks 
of recurrent insanity. 

It is a bad sign when a patient will not allow that any- 
thing has been the matter with him, or insists that his con- 
dition has been caused by his friends shutting him up, ignor- 
ing all that occurred before he was shut up, and attributing 
evil motives to all concerned. A patient may assert wrongly 
that he has recovered, or that he never was ill at all ; that 
his delusions, so called, were not delusions; and that his acts 
were justifiable. Of course, if his delusions are absurdities, 
and he holds them now, his state is not a matter of doubt; 
but a man who has recovered from delusions may be unwill- 
ing to allow that he has held any, and may explain them 
away, singling out the grain of truth that may be at the 
foundation of them, and justifying the whole by this. Now, 
it may be thought that a patient cannot be recovered who 
justifies previous delusions, even if he does not hold them ; 
but much allowance must be made for individual tempera- 



358 THE TERMINATIONS OF INSANITY. 

ment and character. Some men and women cannot bear to 
think that they have been insane, or have entertained insane 
fancies, or done insane acts, and they satisfy their consciences 
and salve their wounded pride by explaining away as much 
as they can. This we must often overlook, and must not too 
rigidly compel confession from patients, or too closely cross- 
examine them as to all the details of the past. As I have 
told you, delusions spring to such an extent out of the feeling 
of the moment, that a patient a month or two afterwards, in 
an altered physical condition, cannot go back to the ideas he 
held in his former state, and may deny that he held them, 
or may justify them, because he is unable now to enter into 
a contemplation of another state of things. You must con- 
sider the whole manner in which he speaks of the past : if he 
is ashamed of himself, and would rather let the subject alone, 
and talks rather of the future, and of returning to work or 
home, and if all his talk of the present and future is healthy 
and hopeful, we must not be too particular in judging of the 
manner in which he speaks of the past. But if he is perpetu- 
ally harping on the past, reviewing and discussing every de- 
tail, always complaining and threatening retaliation, law- 
suits, and the like — if he craves for liberty in order to set 
about such proceedings rather than to return to his usual 
avocations — we must look with suspicion on his condition, 
and advise further detention and surveillance, though possibly 
in a modified form. In coming to a decision on such cases 
there is no general rule to be laid down or observed. Ex- 
perience, and the intuitive appreciation of insanity which 
experience gives, are the only guides to a right judgment. 

Another patient may not deny that he has had delusions, 
insanity may ana * may not seek to explain away or justify them, 
be concealed, j^j. } ie w -v| assure us that he holds them no longer. 

There may have been much discussion as to some one or two 
special delusions which remain after all acute symptoms have 
subsided, and our patient, grown cunning by experience, and 



THE TERMINATIONS OF INSANITY. 359 

gathering that so long as he holds these opinions he will be 
restrained and looked on as insane, suddenly gives them up, 
professes that he holds them no longer, and perhaps expresses 
an unnecessary degree of astonishment at his ever having 
held them at all. Yet he may hold them all the time, only 
denying them to regain his liberty. Here you must take 
into consideration the whole history of the case. A patient 
who, during a somewhat acute state of insanity, entertains 
various delusions, will probably lose them as he passes into 
a quiet convalescent state. There will be marked improve- 
ment in his whole condition; sleep will return, regular habits 
of eating, attention to cleanliness, fondness for ordinary occu- 
pations and amusements ; and, in accordance with all this, 
we should expect also that the delusions and fancies of the 
insane mind will pass away. But if a man tells you that he 
has lost his delusions, and yet you observe no change for the 
better in his habits and appearance — if he still dresses in an 
extraordinary way, and behaves outrageously — we cannot 
believe his assertions to be true. With the inconsistency of 
a lunatic, he may act a delusion at the very time that he 
denies that he entertains it. We must endeavor to discover 
whether he has really lost them, or whether he is merely 
making the assertion to deceive us. Possibly we may find 
that although he denies them to us, he will confess them to 
his relations and friends, to other patients, or the attendants. 
He may betray them in his letters. He will deny that he 
hears voices, yet we may overhear him talking when alone 
to imaginary people, and answering imaginary questions. 
We may notice ornaments about him illustrating delusions 
concerning imaginary rank and titles, or unfounded hostility 
towards wife or friends shows that he still entertains the 
former delusions concerning them. 

Where a patient's insanity is displayed not so much in 
delusions as in acts, and partakes more of the nature of so- 
called moral insanity, it is not easy to say whether he is or 



360 THE TERMINATIONS OF INSANITY. 

is not recovered. For he is restrained and kept from acts 
of extravagance or vice, and we cannot, therefore, be sure 
whether he would return to these or not. But from his gen- 
eral behavior, and by comparing his present with what we 
hear of his former mode of life — by observing whether there 
is anything absurd or bizarre in his ways or acts — we may 
arrive at a tolerably accurate diagnosis. We shall also take 
into consideration the way in which he justifies his former 
acts, for this he may do in a manner highly indicative of in- 
sanity. I had rather hear a patient deny than justify a very 
insane act. In the confusion of his brain he ma}^ have almost 
forgotten it ; or he may prefer to deny it altogether ; pleading 
"not guilty;" but I have known a lunatic justify acts that 
none but a lunatic would have perpetrated, and none but a 
lunatic would defend. 

We may have our doubts as to a patient's recovery, may 
disbelieve his statements, and think his friends too sanguine, 
but may hesitate about detaining him longer in an asylum. 
There comes a period in the history of almost every con- 
valescing patient at which change is necessary, when, if he 
be further restrained in the same place and in the same 
fashion, he is likely to go back rather than forwards^ ^Al- 
though we do not consider him fit to be restored at once to 
full and unrestricted control over himself and his affairs, we 
a trial to be wish to test his recovery, to put him on his trial, 
recommended. an( j fa ^ ve ]^ m cnan g e \> The law provides for this 

emergency. The Commissioners in Lunacy, upon the re- 
ceipt of a certificate of the patient's fitness, will grant " leave 
of absence" from the asylum, hospital, or house, for any 
reasonable length of time, provided the patient is removed 
"under proper control" to a place specified. The control 
may be that of relatives or friends, or an attendant, or 
medical man. This plan I advise you to adopt in every 
case in which you are not quite certain how the patient 
will go on when the restraint is first removed/, It is often 



THE TERMINATIONS OF INSANITY. 361 

an advantage that the individual should know that he is 
only away on trial and probation, and that he can be brought 
back at a moment's notice. It enables us to judge whether 
he is cured or not : many improve in a remarkable manner 
when thus sent away, and our forebodings are not real- 
ized; others show that their seeming recovery was not real, 
and may be brought back without trouble and delay, and 
their friends, seeing that the trial has been a failure, are 
more satisfied than they would have been had it not been 
granted. In many cases we can never, so long as a patient 
is subjected to the restraint of an asylum, ascertain his ac- 
tual mental condition in the way that it is revealed by his 
being left comparatively to his own devices for two or three 
months. 

In speaking of the pathology of insanity, I mentioned a 
class of cases where the insanity is remittent or Re currin g 
recurring, a period intervening in which the patient insanit y- 
appears either quite or nearly recovered, or at any rate, 
altogether different from what he is during the time of the 
attack. This recurring insanity is not uncommon, but is 
very unfavorable as regards prognosis, and very difficult to 
deal with when the periods of apparent sanity are of any 
duration ; for the patient then demands his release, and may 
threaten us with the consequences of his detention. As I 
said in the former lecture, we may see a man apparently 
recover from an acute attack, and just as we think him well 
and able to go out into the world, without any reason or 
warning he breaks down, and the whole of the symptoms 
recur, and this may happen again and again during many 
years. I do not know that we have anything to warn us 
that a patient's insanity will be recurring, except that the 
recovery is usually very rapid. Rapid recoveries must always 
be looked on with suspicion. The slowest recoveries that I 
have ever seen in patients suffering from acute mania have 
been in those who have remained well ever since. If a 



362 THE TERMINATIONS OF INSANITY. 

patient recovers very rapidly, probably he will not remain 
well long; but we may not be able to detain him, and he 
will go out, break down, and be again admitted. Some are 
never well long enough to gain their release. They alter- 
nate, month about, between comparative sanity and most 
evident insanity, mania or melancholia ; and as time goes on 
their sanity will be less apparent, and the violent stage will 
alternate with a state of quiet and harmless imbecility, the 
mind wearing out, but the recurring disease being as potent 
as ever. 

Now, it is important that we should endeavor to break 
through the habit of periodical attacks, to destroy the perio- 
dicity of disease. We cannot do it by medicine ; but it may 
be done sometimes by change of scene. In most cases change 
of scene and surroundings will have some effect, will lengthen 
the period of sanity, or render less severe the attack ; but in- 
stances have come under my notice where, by a judicious 
change or series of changes, the periodical attack was finally 
averted and the patient cured. This should always be tried 
where means are forthcoming, and where the attack is of a 
nature to allow of its being treated out of an asylum under 
proper control. It sometimes happens that patients will 
brook no control, and will have their entire liberty or noth- 
ing. If they are subject to paroxysms of sudden homicidal 
mania, it may be impossible to allow of their leaving an asy- 
lum; but in many of these recurring cases of mania or mel- 
ancholia it is quite possible to try the effect of change of 
scene ; and I hold that no patient has been fairly tested till 
some such plan has been tried. 

A person who suffers from recurrent insanity is, above all 
others, such as is described by Lord Coke as " a lunatic that 
hath sometimes his understanding and sometimes not, ali- 
quanclo gaudet lucidis intervallis, and therefore he is called 
non compos mentis, so long as he hath not understanding." 



THE TERMINATIONS OF INSANITY. 3G3 

The older lawyers contemplated the existence of what they 
called lucid intervals in all lunatics, who, during Lucid 
such lucid intervals, were held to be capable of enter- intervals - 
ing into marriage, or contracts, or of making a will. There 
was no legal difference between one lunatic or another as 
regarded the probability of a lucid interval occurring: in fact, 
all that was known in those days concerning lunacy was de- 
rived from the lawyers, the medical profession being very 
little consulted in the matter. In the present day the doc- 
trine of lucid intervals and of partial insanity has been much 
upset by decisions, at any rate in civil courts. The existence 
of insanity, however slight, has been held to invalidate any 
civil act, and the existence of a recurrent insanity, if thor- 
oughly proved, would, in my opinion, vitiate anything done 
in the lucid interval. At the same time, it is to be remem- 
bered that lunatics have been admitted as competent wit- 
nesses in courts of law, and many lawj'ers would sanction 
the signature of a lunatic to a deed, if it could be proved that 
he was at the time in a lucid interval, and understood the 
nature of what he was doing. Signatures are constantly ob- 
tained, and the validity of them must depend upon the cir- 
cumstances of the case — not upon any general principle — 
for unless a man is pronounced insane by a commission tie 
lunatico inquirendo, he is, prima facie, supposed to be sane. 
On this point a circular was issued, in 1864, by the Commis- 
sioners in Lunacj', which I subjoin : 

]9 Whitehall Tlace, S. W., July, 1804. 

Sir: The Commissioners in Lunacy have, from time to time, and 
more especially in a recent case, had occasion to consider the question 
of the signature of documents or papers affecting propert}' by patients 
detained under medical certificates as insane. It is no part of the duty 
of the Board to determine the general question of the validity of such 
transactions, which is one for the decision of courts of law or equit} T in 
each particular case. 

The Commissioners, however, are decidedly of opinion that, as a 
general rule, proprietors and superintendents, having charge of persons 



364 THE TERMINATIONS OF INSANITY. 

as of unsound mind, ought not, in any circumstances, to sanction, or 
knowingly afford facilities for, the signature by such persons of deeds 
or documents, cheques or other papers disposing of, or otherwise affect- 
ing, their property or income. Any transaction relative to the property 
of lunatics, or alleged lunatics, should be conducted under the authority 
of the Lord Chancellor, and the provisions of the Lunacy Regulation 
Acts, the Trustees' Relief Act, or other statutes applicable to the cir- 
cumstances. Any persons taking upon themselves to act without such 
authority incur grave responsibility, and the Commissioners will in 
future expect from you a strict compliance with the rule they have here 
laid down. 

I am, Sir, your obedient servant, 

W. C. Spring Rice, Secretary. 

Although I have spoken in a gloomy strain of the subse- 
Eecoveries quent history and fortunes of recovered lunatics, 
numerous, fo - g no £ foe less certain that recoveries do take 
place in great numbers, and that modern science tends to 
increase the number. If we take the records of an asylum, 
as Dr. Thurnam did, examining all the cases admitted, cura- 
ble and incurable, the percentage of cures will probably be 
about that which he gives! But if we take curable cases 
only, it will be much higher — nay, I venture to say that if 
w r e were to examine curable cases only, and of these, such as 
were submitted to skilled treatment so soon as symptoms of 
mental derangement were discovered, we should find that 
three-fourths, or even more, had recovered. Numbers of 
such patients never go into an asylum : their malady is 
slight, and passes off, or a cure is effected without the neces- 
sity of removal from home, and so they do not swell the 
statistics of recorded recoveries. It stands to reason that the 
worst cases are sent to asylums. It is a fact of experience, 
that many are not sent till they have reached the stage of 
incurability. And when we consider how many are sent 
thither afflicted with general paralysis, epilepsy, or con- 
genital defect of mind, it is clear that any percentage of 
cures must be greatly affected thereby. 



THE TERMINATIONS OF INSANITY. 365 

You must labor, then, in jour position as medical advisers, 
to bring under treatment at as early a period as possible all 
who show any symptoms of mental disorder. Where you 
know of, or have reason to suspect, the presence of hereditary 
taint, it behooves you to watch narrowly for the earliest in- 
dications of evil, to ward them off by judicious treatment, 
medical and moral, and if this cannot be carried out without 
legal interference, to insist on its being at once had recourse 
to. The arrest of insanity in its very beginning is that which, 
above everything, should be studied by all medical men. The 
abolition of the restraint of chronic lunatics has brought 
undying fame to the name of Conoily, but asylums full of 
chronic lunatics are an opprobrium medicorum^ Those who 
pass their lives in the management of them, in the invention 
of amusements, the planting of fields and gardens, and the 
feeding, tending, and cleansing of the patients, are apt to 
look upon all this as the end of their labors, and a favor- 
able report from the visiting commissioners concerning the 
state of the house as the summit of their ambition. But he 
who could advance the cure of lunatics in an equal degree 
to that in which Conoily promoted their comfort and happi- 
ness, would win fame no less brilliant, and the gratitude of 
mankind throughout the ages.) 

Even now, in spite of relapses, recoveries are sufficiently 
numerous to repay us richly, and to form a satisfactory basis 
for scientific observation : and if a patient breaks down a 
second time, we may hope again to cure him. The old 
farmer of whom I spoke, after having been in an asylum 
some thirty times, died at last in his own house, among his 
own people ; and on all these various occasions he had gone 
away so much better that he was called " recovered," though 
his mind was not in all respects sane and sound. And others 
I have known, who came again and again, though not so 
often, and finally died, at home of general decay or ordinary 
disease. The ultimate fate of any one who has ever once 



3G6 THE TERMINATIONS OF INSANITY. 

been insane, is very grave, from one point of view — so grave 
as to make us dissuade others from intermarriage and such 
contracts; yet as regards the individual himself there is 
enough of hope to allow of our cheering him at the termina- 
tion of an attack, and trusting to cure him should he have 
chances of another. If? however, you are consulted as to his 
life. chance of life, you will undoubtedly give, as your 

opinion, that it is inferior to that of a sane person. A man, 
we will suppose, has recovered from an attack of insanity — 
his first attack. He is liable to a second — liable, therefore, 
to the various accidents which so often befall lunatics before 
they are placed under proper care and control. And the 
second attack, or the third, may be of a very acute nature, 
in which he may die. Then, being subject to attacks of 
insanity, he may squander his property, lose his business, 
and come to the condition of a pauper ; and if recovery again 
takes place, he may recover only to undergo great privations, 
which may materially shorten life. If you are asked as to 
the probable duration of life of a chronic lunatic confined in 
an asylum, you may speak with greater certainty in view of 
the particular case. Such patients are under constant medi- 
cal care : if they have everything that money can bring, they 
have all that medical skill can do to promote health and 
ward off evil. Their diet and drink are regulated, as are 
the hours of sleep and exercise. If they are in good health, 
and the malady does not tend to wear them out by great 
excitement or depression, their lives may be in no way 
inferior to those of persons exposed to the accidents of every- 
day life. But each case must be judged apart. One could 
not say that the lives of all chronic cases were good. But 
in every asylum you will be shown some octogenarian in- 
mates, who by their long sojourn prove that insanity of itself 
does not shorten life. 

What is the mode and immediate cause of the death of the 



THE TERMINATIONS OF INSANITY. 367 

insane? Many die in the acute stage, and we often feel a 
difficulty in stating in our certificate the exact cause, causes of 
whether after a post-mortem examination or not. a ^ ongstt he 
We see a patient in an attack of acute mania which insane - 
runs a rapid course. Sleep is absent, and in ten clays or a 
fortnight he dies. He gets weaker and weaker, and at last 
collapse sets in, and the heart fails; profuse perspiration 
breaks out, and he gradually sinks from exhaustion of the 
heart's energy. On performing a post-mortem examination 
we find merely signs of great hyperemia of the brain, or of 
increased action, but do not perceive any actual lesion, or 
any trace of that which has caused the stoppage of the heart. 
The patient's strength and nerve-force have in fact been ex- 
hausted, and have never had the chance of being renewed. 
If we examine another case, of much longer duration, the 
same appearances may meet us. That which happens to one 
in a fortnight, may, in another, come about in two or three 
months. Sleep is not so completely wanting, the violence is 
not so great or so incessant, yet the waste is greater than the 
repair, and death follows ; and on examination we are equally 
at a loss to give a definite reason for the termination of life. 
I have seen medical men who were unaccustomed to make 
post-mortem examinations of such patients greatly surprised 
at finding so little after such severe disorder and rapid death; 
but the process by which that metamorphosis which goes on 
in our daily lives is arrested or terminated, sometimes leaves 
no marked signs for us to scrutinize after death. Acute 
mania, like the poison of the serpent or prussic acid, may 
kill and leave no trace. We know, by watching the patient's 
strength slowly ebb and fade, that exhaustion is the mode of 
death; but it is the disease which kills, as do typhus and 
cholera, and therefore it is vain to talk about there being no 
such disorder as acute mania, or to say that lesions or marks 
of inflammation are always to be found, whether by the mi- 
croscope or naked eye. Two patients are attacked with acute 



368 THE TERMINATIONS OF INSANITY. 

mania ; in ten days one is well, the other is dead. The same 
thing may happen in less time in the case of two suffering 
from delirium tremens. Is it likely that anything like an 
appreciable organic lesion has existed in either of these cases 
which can have been perfectly removed by one long sleep ? 
That there have been disturbances in the molecular consti- 
tution of the nerve-centres, we know; but we do not be- 
lieve that these would be discernible, even if we could apply 
the microscope during life. 

It may often be, then, that we shall have to describe pa- 
tients as dying of acute mania or acute melancholia produ- 
cing fatal exhaustion; and to this we may have to add that 
such exhaustion was accelerated by the impossibility of giv- 
ing sufficient food. Many are brought to us who have been 
allowed to go so long without being fed, that all hope of sus- 
taining life is past. 

When, however, we survey the non-acute forms of insan- 
ity, or the patients who live for years in a chronic state, 
it appears that many, I might say most of them, die not of 
the insanity, but of diseases to which sane people are liable. 
According to the insanity, however, and the condition to 
which they are reduced by it, they are more or less liable to 
the attacks of other diseases. Patients suffering from chronic 
mania or monomania, who" have a considerable amount of 
nervous energy and of intellect, albeit deranged, will live 
much longer, and withstand disease much better, than de- 
mented persons whose vital powers are at the lowest point. 
The demented are very prone to get fat ; taking but little 
exercise, their whole system is feeble, and the heart and 
muscular tissue undergo retrograde metamorphosis. In this 
state their great foe is acute bronchitis; and this, in my 
experience, carries off the majority of them, and, indeed, of 
all chronic lunatics. These very fat patients seem especially 
its victims: the circulation becomes impeded, the heart can- 
not force the blood onwards, they are choked with mucus, 



THE TERMINATIONS OF INSANITY. 369 

and die rapidly. I warn you to watch very closely the ap- 
proach of this malady, if such patients are under your charge. 
The ordinary cough medicines are of little use ; but I have 
found the greatest benefit from the use of a steam-kettle in 
the room: it should be kept boiling night and day, and a good 
large jet of steam should constantly moisten the air. In the 
case of these patients, as with young children, and, in fact, in 
bronchitis generally, I believe this remedy to be of incalcula- 
ble value. In my own experience — which has been only of 
the upper classes — I have not found phthisis at all prevalent 
amongst chronic lunatics. One gentleman died of acute mania 
after an attack of haemoptysis, and in the lungs of two who 
died of general paralysis, tubercles existed ; but amongst 73 
deaths in the last few years, only one was returned as caused 
by phthisis. In the public asylums the proportion of those 
who die of this disorder is large. 

If you ever see much of the insane, you may have to form 
a diagnosis of bodily disorders occurring in patients 

, ° J O I Diagnosis 

suffering from a recent or chronic form of mental oibodiiy 
affection. Most difficult is it at times to ascertain if 
anything be the matter with such people, and, if anything, 
what the seat and nature of the ailment are. One class will 
simulate every kind of disorder, will complain of agonies, of 
obstruction in the bowels or urethra, inability to swallow, 
headache, or sickness — to say nothing of matters more pal- 
pably fanciful, as eruptions, broken bones, or paralyzed limbs. 
Another class will tell us nothing — nay, will strenuously 
deny serious illness — partly from a fear of medical interfer- 
ence and physic, partly because they are too demented or 
deluded to realize their true state, which possibly they attrib- 
ute to supernatural or inevitable causes. In dealing with 
these we have need of an accurate knowledge of disease, and 
of patient and painstaking investigation of every fact and 
every organ. We are prone to think that an individual, 
melancholic and hypochondriacal, may be narrating to us 

24 



370 THE TERMINATIONS OF INSANITY. 

sufferings existing only in his or her hypochondriac fancy, 
as a reason for refusing food, and avoiding all exertion or 
occupation. But they may be real, and we should commit 
a grave error if we ignored their existence. Then a chronic 
case, a demented man, who tells us nothing, suddenly ap- 
pears out of sorts, does not eat as he is wont, sits listless 
and dejected. We can extract no information, no complaint. 
Like an animal or child, he attracts attention only by his 
appearance and the alteration observable. We examine him, 
his pulse and tongue, the state of the urine, if it is possible 
to obtain some, the motions and temperature. If he is ordi- 
narily a hearty feeder, we inquire as to his eating: has he 
lost appetite ? If not, we do not think him very ill. There 
is no better test. But if he will, contrary to his usual custom, 
take no food ; if he appears thirsty and will drink copiously, 
or if he rejects both food and drink, we try to discover what 
is amiss. Is he sick, has he diarrhoea or constipation, has 
he lung mischief? Very insidious is the latter. Great rav- 
ages may have been made in the lung without any cough or 
other sjmiptom to draw attention to the uncomplaining suf- 
ferer. Loss of appetite in old-standing cases is perhaps the 
most valuable warning ; but in those more recent, refusal of 
food is so common, that very close inquiry is necessary, and 
we may have to insist on its being taken in spite of the 
alleged indisposition. But here the latter will be not con- 
cealed, but put forward and dwelt upon, and. it will generally 
be represented as most serious, causing great suffering and 
sense of illness. If we find that the tongue is perfectly clean, 
the temperature normal, the pulse quiet, and urine healthy, 
we shall with reason doubt the statement, and look upon it 
as having a purpose. Nevertheless, cases will often puzzle 
and cause us to hesitate, and we must never be content with 
anything short of a thorough examination of the patient. If 
there is frequent sickness, we must be sure there is no hernia. 
If there be little water passed, or a constant dribbling, we 



THE TERMINATIONS OF INSANITY. 371 

may find a distended bladder. And whenever we hear of an 
unexpected and unaccountable death, nothing but a post- 
mortem examination should satisfy us as to the cause thereof. 
It may often fall to your lot to have to treat chronic cases 
of mania or dementia, patients who are in a state 

1 The treatment 

of unsoundness of mind, but are harmless, not re- of the chronic 
quiring the restraint of an asylum ; they demand, 
nevertheless, careful watching and nursing, being frequently 
in a state of second childhood, like children or even infants 
in uncleanliness, and utterly unfit to take care of themselves. 
Such patients are often found by the Commissioners in private 
houses in a state of great neglect. They are perfectly man- 
ageable without the appliances of an asylum, but require con- 
stant and watchful care. One difficulty you will have to 
encounter is the keeping them clean. Their tendency is to 
sink into an apathetic state, in which they discharge their 
evacuations regardless of place or time, like wild animals or 
very young infants. In or out of an asylum they may cause 
trouble in this respect; but in or out of an asylum dirty 
habits may be much eradicated by careful attendants. Some 
attendants, who have had no experience of such cases, are 
altogether amazed when told that they are to blame for wet 
or dirty beds or clothes. They think that it is a concomitant 
of the imbecile state, no more to be altered than the failing 
memory or the shuffling and feeble walk. You will find, 
however, that a patient must be very far gone indeed who 
cannot be taught the habit of relieving himself at regular 
intervals, and in a proper receptacle. Even when a patient 
is unconscious, and sunk in the last stage of paralytic de- 
mentia, accidents, though they cannot be altogether avoided, 
may be made the exception instead of the rule. And I be- 
lieve that any chronic demented patient, whose mind remains 
the same from year's end to year's end, may be taught to be 
cleanly. Some, who have a good deal of mind, whether re- 
cent or chronic cases, will be dirty wilfully, to give trouble or 



372 THE TERMINATIONS OF INSANITY. 

annoyance. They must be dealt with very firmly, and forced 
to go to the closet or to get out of bed. Imbecile patients, 
who are dirty from sheer want of attention, are at least as 
capable of being taught to be clean as a child of a twelve- 
month, or a dog or cat. In short, patients dirty by night or 
day imply careless or inefficient attendants. Do not listen 
to the excuse that it cannot be helped: change the attendant, 
or threaten to do so, and you will probably find that the 
habit is eradicated. Another circumstance, which is equally 
a test of the care of the attendant, is the presence or absence 
of bed-sores. No chronic lunatic should be kept in bed by 
day and night simply for infirmity, unless he is actually ill. 
He should be washed and dressed, and seated in an easy- 
chair, even if he is unable to walk about. By this method, 
by thorough cleansing, and by thickly powdering with oxide 
of zinc powder any part of the back which is likely to give 
way, bed-sores may be avoided in patients who linger on in 
an extreme stage of paralysis even for years. In such cases 
a wet bed cannot always be avoided ; but proper precautions, 
and the establishment of systematic and regular times for 
micturition and defecation, will reduce " accidents " to a 
minimum. More is to be done by these measures than by 
the use of urinals or other apparatus. Many will not suffer 
them to remain properly adjusted, or cannot bear the pres- 
sure occasioned. Such appliances are costly, often out of 
order, and soon become very offensive. 



LECTURE XVIII. 

General Remarks on Treatment — Importance of Early Treatment to be 
urged by Family Practitioner — Restraint to be advised when neces- 
sary — Objections of Friends to be met — Use of an Asylum — Attend- 
ants — Delusions, how to be met — Asylums not necessary for all the 
Insane — On the Choice of an Asylum — Feigned Insanity — Hints for 
Detection — The Odor of the Insane. 

I have a few remarks to make upon the general treatment 
and management of insane persons, which will occupy the 
present lecture. In all probability but few of you will have 
to treat insanity as a specialty : the majority will meet and 
have to deal with it as it occurs in the course of the practice 
of a physician, surgeon, or general practitioner, and in this 
way you will see patients and their friends at an earlier 
period than those who practice more specially as lunacy doc- 
tors. The friends shrink from calling for the latter's advice 
or assistance till every other means has been tried ; upon 
you will devolve the responsibility of taking the 

•* * * ° Importance 

earliest, often the most important, steps for the <>feari y 
security and cure of the individual. And I assure 
you the friends will prove to you as great a source of diffi- 
culty as the patient himself. They will refuse to believe 
that his mind is affected, and shut their ears and eyes to all 
they hear or see, insomuch that they will say that the dis- 
order commenced quite suddenly, without any warning, on a 
particular day, when every one else has noticed its approach 
for months. Now, in the earliest stages, insanity is a very 
curable disorder; but through the obstinacy of friends it 
happens over and over again that the curable stage is past 
and gone long before any remedial measures have been taken, 



374 GENERAL REMARKS ON TREATMENT. 

and the patient is brought to us a confirmed and hopeless 

lunatic, requiring care not cure, to be shut up in restraint 

for the term of his natural life. And often a patient in this 

stage is put in an asylum for the sake of avoiding trouble 

and expense, who might very well live outside, mixing under 

some sort of surveillance with a family, and with the world 

at large. During the time that an asylum might effect a 

cure, the friends would not hear of sending him thither ; but 

when all hope of cure is over, he is placed there because it is 

cheap and saves trouble. 

Now, I hold that at the present day our method of dealing 

with the insane should be this: First, we should en- 
Duty of the in- -i • 

family deavor to ward on an attack of impending insanity, 

practitioner. _ . ■ . _ . . . _. _ 

and this, 1 believe, may be done very frequently. If 
it is not done, if the storm breaks, and breaks with violence, 
so that the patient, together with those about him, is in dan- 
ger, to an asylum he ought to be sent, where everything sur- 
rounding him is specially adapted to his wants. If he does 
not recover, but quiets down into[a " partially insane " man, 
tranquil and orderly, yet requiring supervision, and unfit to 
be in his own home, he ought not to remain in an asylum, 
if he is capable of enjoying himself in a greater degree be- 
yond its walls J 

At the very commencement of symptoms threatening men- 
tal disorder, you will have the least difficulty in getting 
your advice followed. At this stage you may be able to ad- 
vise and consult with the patient and with his friends at the 
same time, and you may, in forcible terms, lay. down the 
necessity of change of scene, cessation of work, and attention 
to diet and medicines. At this time you have not to incul- 
cate the necessity of resorting to legal measures. Either in 
his own house, or in a friend's, or on a tour with some mem- 
ber of his family, with or without an attendant, the patient 
may pass a period of rest and treatment, and you may reason- 



GENERAL REMARKS ON TREATMENT. 375 

ably hope that your advice as to all this will be followed, and 
if followed strictly, will be attended by recovery. 

I But if the patient gets worse instead of better — if he will 
take no advice, and submit to no treatment except Restraint to 
on compulsion — if delusions show themselves, and beur s ed 

J- y when nece»- 

become more and more formidable, it will be your ^j- 
duty to represent, not to the patient — for this is useless — but 
to his friends, the urgent necessity for legal restraint; that 
he may, in the first place, be kept in safety ; in the second, 
be subjected to treatment with a view to cure. Here you 
will be met with every conceivable objection. Wives are 
afraid to take any step of the kind without the co-operation 
of the husband's relatives — husbands without those of the 
wife. They are afraid that the patient, even if he recovers, 
will never forgive the step you are urging. They would 
sooner wait a little longer, till something occurs that more 
loudly calls for legal interference. They are sure that if he 
is placed in an asylum it will drive him "quite objections to 
mad," when he knows where he is, and sees the bemet - 
other patients. Now, you may assure such people that it is 
absolutely requisite that the individual shall be placed some- 
where under legal restraint; and that if he is insane enough 
to require this, he himself will care little whether the place 
of restraint is an asylum or a private house. If he is indig- 
nant at being restrained, and clamorous for liberty, he will 
clamor as loudly in a private house as in an asylum, and 
probably make more determined attempts to get out, owing 
to facilities for escape being more numerous. If he is wildly 
maniacal, he will care little where he is; if profoundly melan- 
cholic, all places will be to him alike. And as regards the 
other patients, we find that each one is so wrapped in him- 
self, in his own delusions and projects, in his own misery or 
his own greatness, that he little heeds the rest ; and in the 
acute state, at any rate, their presence does him no harm, 
often the contrary. Later, perhaps, he may shrink from 



376 GENERAL REMARKS ON TREATMENT. 

them, when mental health is returning, and then it may be 
advisable that he should be removed from such a scene, and 
placed among sane people. It may be worth while to con- 
sider for a moment the advantages gained by a patient who 
is placed in an asylum, and the mode in which a cure is 
there effected. There can be no question that the perfec- 
tion of treatment would be to place a patient in an asylum 
where the other inmates were not insane, but sane people. 
We should then have all the advantages we have at present 
without any of the drawbacks. The patient would be sur- 
rounded by a fresh scene and fresh faces. New subjects 
would be presented to his mind by way of occupation and 
amusement, to take the place of his morbid ideas; but this 
proceeding cannot be carried out ; we therefore fall back on 
asylums as they are. Here the patient finds, above every- 
Theuseof an thing, rest and safety. He is kept from accident 
asylum. an( j gu^de. He is cut off from his friends and 

all with whom his delusions are so often connected. And 
here I would urge you to impress upon the friends the neces- 
sity of leaving a patient alone and unvisited when he is first 
placed in an asylum. To sever home-ties and ideas is one 
of the main objects you have in placing him therei and if 
friends, in mistaken kindness, visit him from day to day, he 
might as well be at home. All letters must, in the majority 
of cases, be interdicted, at any rate at first, and the patient 
must be told plainly and openly that he is not well enough 
to carry on a correspondence, and that his letters, if written, 
will not be sent. Nothing irritates a man more than to be 
told that his letters are sent, while he finds, by the absence of 
all replies, that they are not; or concludes that if sent, they 
are disregarded by those to whom they are addressed. Pa- 
tients are not to be treated entirely as children, nor can they 
be satisfied with trifling excuses and evasions, though they 
resemble children in that we are obliged to act for them, and 
cannot consult with them. In quiet, then, and forced inac- 



GENERAL REMARKS ON TREATMENT. 377 

tivity, many a man recovers in an asylum by rest alone with- 
out any very special treatment, so far as medicine is concerned. 
His health may be tolerably good ; possibly he refuses to take 
medicine, and may not be in a condition in which we care to 
force him to swallow it. The struggle and ill-feeling thence 
arising would more than counterbalance the probable good 
to be gained from the physic, yet he may recover, and that 
in no long time. He recovers simply because he has been 
kept in an asylum, or, as some would say, because he has 
been subjected to moral treatment. Doubtless, you have all 
heard of the moral treatment of insanity. But shutting a 
man up in an asylum can hardly be called moral treatment. 
It is simply restraint, which may be highly beneficial, and 
even remedial, as it is a means whereby the patient obtains 
rest and seclusion from all that is harassing and vexing, but 
it is not what I understand by moral treatment. For in old 
days men were placed in asylums, and then and there con- 
fined in a restraint-chair or strait-waistcoat, by leg-locks and 
handcuffs, and fed, washed, and dressed ; and this, together 
with some purging and blistering, constituted the treatment. 
But we should hardly call this moral treatment. By the 
latter, I mean that [personal contact and influence of man 
over man, which the sane can exercise over the insane, and 
which we see so largely and beneficially exercised by those 
having the gift, whether superintendents, matrons, or attend- 
ants. There can be no proper treatment of an insane person 
without it, and, beyond all question, the recovery of many 
has been delayed or prevented by its absence. There are 
patients, however, who are not within its reach< A ^A man or 
woman in a state of acute delirious maniajis beyond moral 
treatment, and needs only that which is physical or medi- 
cinal. That is why it is of little importance whether we 
treat such in or out of an asylum, provided we can^place 
them in a suitable apartment. But we may see another who 
will never get well out of an asylum. What do we notice 



378 GENERAL REMARKS ON TREATMENT. 

here ? . A morbid and intense pliilautia, an extreme concen- 
tration of the whole thoughts and ideas on self and al.l that 
concerns self: whether the individual's feelings are those of 
self-satisfaction and elation or of depression, whether he 
thinks himself the greatest man in the world or the most 
miserable, he is constantly absorbed in the contemplation of 
self, and thinks the whole world has its attention directed to 
him. Wow, when such a being is at home, he generally con- 
trives to make himself the centre and focus of every one's 
regard ; and if away from home, in a lodging or family,, he 
may be able to do the same thingj-nay, in the majority of 
cases, this cannot fail to be the case, for the arrangements of 
the household must more or less depend on the presence of 
such an inmate jLbut place him in an asylum of fifty patients, 
and he occupies at once merely the fiftieth part of the atten- 
tion of those about him.A He is given to understand that the 
establishment goes on just the same whether he is there or 
not, but that being there^he must conform to the rules, his 
going away depending to a considerable extent on his own 
effort^ and his observance of the precepts and advice which 
he receives. He is encouraged to follow the latter by the 
approval of those about him, whose approval he ought to 
value : he is dissuaded or even prevented from doing that 
which he ought not. He is indulged with a certain amount 
of liberty, according as he shows that he is fitted to enjoy it, 
with liberty to go beyond the premises, to visit places of 
amusement, to have money at his command, to choose his 
own recreation and occupation; and this liberty he forfeits 
if he abuses it, and strict surveillance and watching are 
exercised until he shows that he can control himself. 

Now, in all this it is necessary that we have the co-opera- 
tion of attendants. In an asylum such as I have mentioned 
attendants must be numerous, and for the purposes 

Attendants. . . . 

ot judicious treatment an asylum should not be too 
small. A patient may keep one containing only half a 



GENERAL REMARKS ON TREATMENT. 379 

dozen inmates in a continual turmoil, and his self-importance 
is only increased thereby ; but merged among forty or fifty, 
he becomes at once a much smaller fraction of the whole. On 
the other hand, no asylum should be so large as to preclude 
that personal attention which constitutes real moral treat- 
ment. The day may come when ladies will devote them- 
selves to the nursing of lunatics, as they now labor in general 
hospitals. But as matters stand at present, we have to con- 
trol insane ladies and gentlemen by means of servants, and 
great difficulties thus arise. A good attendant is a treasure 
beyond price, but it is not in the power of every one, what- 
ever the desire, to be a good attendant; nascititr, n on fit. It 
requires a combination of patience, tact, and judgment, of 
boldness, firmness, and unvarying-good temper, possessed by 
the few rather than the man}^. Yet we cannot cure patients 
without attendants. Male patients cannot, for obvious rea- 
sons, be attended in all cases by females, whether servants or 
ladies; and gentlemen cannot be procured to act the part of 
attendants, nor would they on many occasions be more fit- 
ting. It is incumbent on us, therefore, to select with the ut- 
most care those to whose charge we are forced to commit the 
insane, to watch them with unceasing vigilance, to remove 
those who, by constitution and infirmity of temper, or weak- 
ness of health, are unfit for the arduous task, and to retain 
by ample pay and reward, by relaxation and indulgence, 
those we feel to be faithful servants. Were I writing a book 
about asylums, I might say more, but other topics demand 
attention. 

By the moral control exercised personally by man over 
man, the patient's thoughts and feelings are to be MO rai treat- 
directed from his morbid self-contemplation to that ment - 
care and concern for others which is his normal state. Those 
about him will endeavor to supplant by other ideas, subjects, 
and occupations, his delusions and insane thoughts. As the 
former gain a foothold and predominance, the latter fade and 



380 GENERAL REMARKS ON TREATMENT. 

disappear. Direct controversy on the truth or falsehood of 
delusions does little. Towards the close of an attack of in- 
sanity, in the period of convalescence, a patient may now and 
then be convinced of the falsehood of one of his fancies by 
direct demonstration ; but at the height of the disorder this 
cannot be done, and it is often unwise to attempt it. Con- 
troversy perpetually renewed only tends to fix and confirm 
the fancy, which often departs quickly if never alluded to. 

Under the head of moral treatment must be considered 
the question of occupation, exercise, and amusement; for 
nothing is of greater importance, not only to the welfare of 
the chronic, but to the cure of recent cases. All three are 
in turn requisite and indispensable, though not all are 
equally required by the same individual. To one bodily 
exercise is a necessity. In subacute, restless, sleepless 
mania, protracted muscular work will bring sleep, and act 
as a sedative more efficacious than drugs. Hard exercise 
w^ill distract another whose thoughts are fixed unceasingly 
on melancholy subjects. I have known a man dig all day 
in the garden — dig a pit and fill it up again if other occupa- 
tion for his spade was not to be had — and profit thereby. 
In public asylums there are far more opportunities for giving 
the inmates hard bodily work than exist among private 
patients. It is very difficult to subject the latter, particu- 
larly ladies, to sufficient exercise. Many a lady would be 
the better, could she be made to do the hard day's work 
done by many in our public asylums; but beyond walking, 
it is next to impossible to provide any exercise for her. Gen- 
tlemen fare somewhat better : they can ride, play cricket, 
billiards, skittles, football ; but play is not the same thing as 
regular work, and regular work and long-continued exercise 
are of more value than the short but severer labor of games. 
So with regard to mental exercise and occupation. There 
are many brains which require to lie fallow and do nothing; 
if they must be amused, we recommend a course of Pickwick, 



GENERAL REMARKS ON TREATMENT. 381 

or such like fare, or backgammon, or bagatelle ; but some 
patients require harder mental work. To distract their 
thoughts they need to fix their minds on a subject deep 
enough to engross attention, and employ them day after day, 
and week after week. Such are generally intellectual people, 
and their occupation must be intellectual. For them I have 
found no work so suitable as the study of new languages; it 
is intellectual without being emotional, and does not require 
a great number of books or much assistance. I have known 
ladies study Greek and Hebrew, to say-nothing of German, 
Italian, and Spanish. There is no end to this occupation, 
and to a busy mind it is often very fascinating. But people 
differ: another may prefer some new fashion of embroidery 
or lace-work ; and drawing and water-color painting should 
be encouraged in all who have the very slightest artistic 
leaning. 

You will see recorded in books how, by various devices, 
delusions have been dispelled. A woman thought H ow delusions 
that frogs were in her inside. Her physician intro- aretobemet - 
duced some frogs into the nightstool: she believed that she 
had passed them, and was cured of her delusion. But by 
such a scheme you admit the truth of the delusion, and, by 
inference, of all other extraordinary fancies which may be 
alleged. A patient may say, " True, I have got rid of six 
frogs, but others are still left behind. " You cannot then say 
the whole thing is an impossibility and an insane delusion. 
A patient of mine who hears voices and noises, once heard 
at night a knocking or ringing at the front door. Her nurse 
treated this at first as one of her delusions, but on its repeti- 
tion discovered that a policeman had rung, owing to a win- 
dow having been left open. The patient has ever since 
triumphantly quoted this as a proof that her so-called delu- 
sions are realities. Never be tempted by any present chance 
of success into admitting the truth of a delusion, or doing 
anything which by inference admits the same. Sooner or 



382 GENERAL REMARKS ON TREATMENT. 

later, in the present or in some subsequent attack of insanity, 
the patient will turn round and place you in a position of 
difficulty owing to your having made such a concession. 
And be not too anxious to prove the falsity of a delusion. 
Frequently the patient starts from some premises which can- 
not be absolutely disproved, and in logical argument may 
seem to have the best of it. Rather try to oust the idea by 
the substitution of others. It is astonishing how patients 
ignore proof and demonstration. The people they say are 
dead stand before them alive and well, yet they declare it is 
some one else. The partaking of food does not make them 
think the less that their throat is closed, or their inside com- 
pletely gone. 

The more acute the insanity, and the more variable and 
numerous the delusions, the more favorable is the prognosis. 
When there is considerable disorder of the bodily health, 
sleeplessness, disinclination to eat, emaciation, or constipa- 
tion, we may hope that delusions will vanish as the health 
improves. If it improves, and there is not pari passu a cor- 
responding improvement in the mental symptoms, the prog- 
nosis is unfavorable. If the health is completely restored, 
if the patient sleeps well, eats and drinks well, regains flesh 
and looks, and still delusions remain, our augury as to the 
final result will not be encouraging. Perhaps this is why 
patients get well after many years of melancholia. During 
all the time they remain in a depressed state, both of body 
and mind, and generally look thin and miserable, refusing 
food as much as possible, and being altogether out of health. 
The chronic cases in asylums who best preserve their health, 
and look fat and ruddy, and live the longest, are those whose 
delusions are not of deep depression, but of what we term 
mania or monomania. 

I have already said, tfiat at a time when an asylum is 
Asylums not necessary and offers the only chance of cure, the 
!mX ar iLa ne. friends of a patient will often do anything rather 



GENERAL REMARKS ON TREATMENT. 383 

than send him there, will go to any expense to avoid the 
stigma of the asylum, and ran great risk of violating the 
law. But when the case has become chronic, and the patient 
is a harmless monomaniac or dement, they cast about to 
discover how he may most cheaply be kept for his natural 
life. An asylum offers great advantages in this respect — for 
there are asylums of all grades — and to an asylum he goes. 
[The question of restraining chronic lunatics, whether private 
or pauper, in asylums, is one which is attracting, and will 
attract, attention more and more. The notion that all in- 
sane persons must dwell in them has arisen from various 
causes"^ For generations such people were looked upon, not 
as sick, but as a class apart from all others. They were 
handed over to be kept in houses, the proprietors of which 
were not medical men, but laymen, ignorant and uneducated. 
[No one in those days thought the insane capable of mixing 
with sane members of society. In asylums they dwelt from 
year to year, a few walking beyond the premises, but none 
sleeping beyond, or going to any place of amusement like 
ordinary men. _Now, from all asylums patients are sent to 
the seaside, to the theatre, the picture galleries •[ each pro- 
prietor vies with his fellows in providing recreation and en- 
tertainment for his patients — in proving, in fact, how little 
they need the restraint of an asylum. There will always be a 
certain number who cannot be allowed so much liberty, who 
cannot be taken to the seaside, who cannot even walk be- 
yond the bounds of the asylum grounds, whose life is one in- 
cessant struggle to escape by fraud or force, or execute, per- 
chance, some insane project fraught with danger to them- 
selves or others. Some there will be whose limited means 
procure for them greater luxury and enjoyment amongst the 
numerous boarders of an asylum than could be afforded were 
they placed alone in a private family. [But there are many 
with ample means, patients who make the fortunes of asylum 
proprietors, whose lives would be infinitely happier did they 



384 GENERAL REMARKS ON TREATMENT. 

live beyond asylum walls] I would refer you to what Dr. 
Maudsley has eloquently written on this subject. After 
mentioning various objections urged against their release by 
the advocates of the present state of things, he says : " An- 
other objection to the liberation will be that the insane in 
private houses will not be so well cared for as they are, nor 
have any more comfort than they now have in well-conducted 
asylums. The quarter from which this objection is urged 
taints it with suspicion : I never heard it put forward but by 
those who are interested in the continuance of the present 
state of things. Those who make it appear to fail entirely 
to appreciate the strength of the passion for liberty which 
there is in the human breast; and as I feel most earnestly 
that I should infinitely prefer a garret or a cellar for lodgings, 
with bread and water only for food, than to be clothed in 
purple and fine linen, and to fare sumptuously every day as 
a prisoner, I can well believe that all the comforts which an 
insane person has in his captivity are but a miserable com- 
pensation for his entire loss of liberty — that they are petty 
things which weigh not at all against the mighty suffering 

r-O-La life-long imprisonment." 

' VHow are you to know if a patient is capable of living be- 
yond the walls of an asylum ? The answer is simple ; give 
him a trial \ many unpromising cases I have known to bene- 
fit so much by the change that they would scarcely have 
been recognized. Few chronic lunatics are dangerous to 
others : these are easily known, and we should be slow to 
place in a private family any one who has ever committed 
a homicidal act, unless he is fully and perfectly recovered ; 
suicidal patients require the protection of an asylum so long 
as any insanity remains, but there are scores of eccentric 
monomaniacs who are perfectly harmless, who only require 
surveillance and a limit to their supply of money, and can 
enjoy life thoroughly amidst the amusements of town or 
sports of the country, their eccentricities being greatly 



GENERAL REMARKS ON TREATMENT. 385 

smoothed away by the constant society of educated ladies 
and gentlemen. \As the last generation did away with the 
fetters and mechanical restraint used in asylums, so let the 
present release from the restraint of an asylum all those 
capable of enjoying a larger amount of liberty and a freer 
atmosphere than that in which they now fret and chafe. 

If an asylum is inevitable, and thither the patient must 
go, the question will arise, how is a choice to be 0n the choice 
made. Various points must here be considered. Is ofanas y lum - 
the case likely to be of some duration ? or is it acute and ur- 
gent, requiring immediate restraint? Is transit to an asy- 
lum likely to be difficult? Is the patient, when placed there, 
likely to be able to go beyond the premises ? Is it desirable 
that he should be near, or at a distance from, his home and 
relatives? Are there circumstances about the case, such as 
sexual excitement, which make it essential that he or she 
should not come into contact with patients of the other sex ? 
All these matters will guide us in the choice of an asylum. 
It may be important to have recourse to the nearest and 
most easy of access — to one within a cab or carriage drive. 
In many acute cases, especially of females, it may be most 
prejudicial to place the patient in contact with others of the 
opposite sex. In some cases a very small asylum, where the 
routine is domestic and home-like, is advantageous, but other 
patients may cause too much commotion in such a one, and 
may do better when merged in the community of a more popu- 
lous institution. Much will, of course, turn upon the ques- 
tion of expense. As a rule, the cheaper the terms the larger 
is the asylum; but for some, a large and cheap asylum may 
act more beneficially, so far as cure is concerned, than a 
small one, where the individual may be the object of even 
too much solicitude. Where there is no hope of cure and 
the case is chronic, the patient should be placed where he can 
have the greatest amount of occupation, amusement, and lib- 
erty, compatible with his safe-keeping on the one hand, and 

25 



386 FEIGNED INSANITY.. 

his peculiar tastes and idiosyncrasies on the other. It is too 
much the fashion to think that all asylums must be in the 
country. Green fields, though charming at first to denizens 
of a town, are extremely monotonous, and many a patient 
would gladly exchange his country walks and muddy lanes 
for the shops of Regent Street or for Rotten Row. 

Next, I must say a few words upon feigned insanity. A 
Feigned disordered mind has been simulated from the earliest 
insanity. a g eg — witness the dementia which David successfully 
feigned, and the imbecility which saved the life of Lucius 
Junius Brutus — and it will be assumed perpetually by those 
who have a motive for shifting from their shoulders the re- 
sponsibility of their acts. Fortunately few know how to 
feign insanity. It is only a Shakspeare who can depict the 
assuming of a Hamlet or an Edgar. The majority of simu- 
lators are clumsy performers, whom you will detect without 
difficulty; but here and there you may chance to see a case 
which is not so easy to decide, and which, though eventually 
you may be satisfied as to its character, cannot be recognized 
at a moment's notice. Doubtless they who have the insane 
ever before their eyes will most readily detect the sham dis- 
order, yet there are certain points which will enable you to 
come to a conclusion respecting the greater number of cases. 
If we except the instances of hysteria, catalepsy, pretended 
fasting, and the like, which can hardly be called feigned in- 
sanity, we shall find that most persons who simulate the 
malady have an obvious motive for so doing. Therefore we 
do not meet with it frequently in ordinary private practice ; 
but if any of you become surgeon to a jail or to the army, 
you will not seldom be called on to see malingerers who 
adopt this as a means of getting to comfortable asylum-quar- 
ters, or obtaining a discharge from duty. As, however, men 
do really become insane under the same circumstances, you 
will have carefully to discriminate between the real and af- 
fected symptoms. 



FEIGNED INSANITY. 387 



Uneducated as the mass of such persons is, the attempt 
will be clumsy and generally easy to detect: but here and 
there an educated man, who brings himself within reach of 
the law, may with greater success carry on the cheat. 

The first remark to be made is, that the insanity simulated 
may be transitory or persistent. The individual may pre- 
tend that he was in a delirious or unconscious state at the 
time the criminal act was committed, or he may be appa- 
rently insane at the time we see him. Secondly, he may be 
in an acute and active state of feigned excited mania or mel- 
ancholia, or may pretend to be in a quiet and apparently 
chronic condition of monomania or dementia. Thirdly, he 
may put on this appearance soon after the commission of his 
wrong act, to make it appear that it was committed by him 
while insane ; or he may feign insanity while in prison, to 
get away to the better fare and idle life of an asylum. 

If you are told by a prisoner that at the time he committed 
the act he did not know what he was about, or that Insanity 
he has no recollection of it, he virtually simulates P leadedt0 

J excuse a 

the form of transitory mania which is seen occasion- former act. 
ally in conjunction with epilepsy, or taking the place of the 
latter. You will recollect, however, that such attacks are 
extremely rare, that they are not usually so transient as to 
be unnoticed by others, or so severe as to take away all rec- 
ollection of what was done in them. Here you will inquire 
into the previous history of the individual as regards former 
attacks of insanity, epilepsy, blows, or cerebral affections. 

He may tell us that he suffered from an irresistible im- 
pulse to commit the act, from some sudden and overwhelm- 
ing idea : he may simulate the so-called impulsive insanity. 
Applying what I have said already concerning this, you will 
look for other symptoms, for a history of previous attacks or 
previous head-affections : you will not consult the individual 
about these, for you may easily put such into his mouth, but 
to the best of your ability arrive at an account of his past 



tion. Comparing a true with a feigned case, I may 
say, generally, that a real lunatic, when approached 



388 FEIGNED INSANITY. 

life : and you must consider the character of the deed not 
only as regards its enormity, but also its senselessness, want 
of motive, or eccentricity. Such acts, if really committed 
under the influence of either of these forms of temporary 
insanity, are usually violence against self or others. If this 
plea is put forward as an excuse for small and petty thefts 
or forgery, acts of indecency or exposure of person, we may 
reasonably suspect it. The latter are committed by madmen, 
but not by those whose insanity passes off so soon as the act 
is over. 

More commonly, however,, we are called on to see a person 
who is apparently insane at the time of our inspec- 

assumed at 
the time of 
inspection. 

by a stranger, appears at first rather better than 
worse, and more on his guard ; he tries to bring his wits to- 
gether and understand what is going on. But a sham lunatic, 
when we go to him, redoubles his efforts to seem insane : he 
is more energetically noisy, idiotic, and maniacal. A sham 
lunatic, recollect, always wishes to be thought a lunatic. If 
we ask him whether he is out of his mind, he tells us at once 
that he is. In fact, he dare not say the opposite ; whereas a 
real patient rarely confesses it, unless he be in the depth of 
melancholia. 

Feigned insanity is almost always overdone.. As there is 
no subject on which such erroneous notions prevail among 
people in general, so the imitation is, with rare exceptions, 
a bungle. If noisy and violent mania is the form assumed, 
detection is easy. The malingerer, unlike the true maniac, 
will tire himself out and go to sleep. No sane person can 
maintain the incessant action, singing, and shouting of a 
genuine maniac for any but the shortest time. No genuine 
maniac would, in the middle of all this, at an early stage of 
the attack, go to sleep, and sleep many hours. Watch such 



FEIGNED INSANITY. 389 

people without their knowledge, and you will have little 
doubt as to the case. 

If a less excited mania is feigned, and the feigner will talk 
and answer questions, he generally overdoes his part by pre- 
tending to have lost all reason and memory. He will not 
give one correct answer to the simplest question; he will not 
know his own name ; but will display an ingenuity in evad- 
ing answers and in talking nonsense entirely at variance 
with the loss of mind he pretends to have suffered. Or he 
will answer questions correctly about everything that does 
not concern himself, but so soon as we question him as to his 
crime or history, he becomes suddenly demented and entirely 
deprived of memory and intelligence. Loss of memory is not 
common amongst the insane, except in cases of dementia, 
primary or secondary. It may be feigned, but will rarely be 
a clever simulation. Here we must look for an absence of 
mind; and if we see a presence of mind, and a sharpness 
and quickness displayed in many ways, the notion of de- 
mentia is incompatible. Dirty habits may be adopted to 
further the deceit, and malingerers will daub themselves 
with, or even eat, their faeces; but in conversation w 7 e may 
generally discover that they are not so lost as they seem. 
Frequently something casually mentioned in their presence 
is done in consequence of the hint, showing that their atten- 
tion has been fixed on all that has been said. 

A man may feign melancholy, or sit silent and desponding, 
and say nothing. JJere some knowledge of the insane may 
be requisite to guide us to an opinion. He may refuse his 
food, and say that poison is put in it. We must watch him, 
and look for physical symptoms. Is his tongue clean, his 
skin cool, and pulse normal? Does he sleep well at night? 
Does he alter his conduct according to that which is said in 
his presence? Does he dress and undress himself ? Melan- 
cholia, or melancholia cum stupore, is a form distinct from 
others, from mania especially, and this distinction is not 



390 FEIGNED INSANITY. 

likely to be carefully preserved by a malingerer. Neither 
mania, melancholia, nor primary dementia comes on in pa- 
tients, full blown, in an hour. The history of the previous 
days is almost conclusive in the majority of cases, especially 
if there is a knowledge of the sleep the pretended lunatic 
has enjoyed. 

The detection of feigned insanity is, and ever will be, 
Hints for de- difficult, when we have to examine men and women 
tection. j n wnom madness and badness are so intermingled 

that observers cannot determine which it is that regulates 
their conduct. Amidst our criminal population are hundreds 
who can hardly be said to be sane and responsible, but who, 
in the lower ranks of life, commit a succession of crimes, 
perhaps of no great magnitude, which render them the almost 
perpetual inhabitants of jails. Some of them are so violent, 
outrageous, and destructive, so silly in their motiveless fury, 
and childish in mind, that we may call them imbeciles or 
insane, and have good grounds for our opinion. Such there 
will ever be on the border-land of insanity. But each of 
these must be judged by himself. My purpose here is not to 
speak of doubtful, but of feigned, insanity — insanity feigned 
by those of whose sanity at other times we have no doubt. 

We cannot depend on any physical signs for the certain 
detection of simulation. We find among the insane the 
pulse neither slow nor quick, a cool head, and normal urine ; 
and he will be bold who shall affirm that he can detect in- 
sanity or its absence by the sense of smell, though such men 
are to be found. Nevertheless, there is almost invariably 
such a disturbance of the health in a person whose insanity 
is just commencing, that our suspicions should be aroused if 
this be wanting. Want of sleep, a coated tongue, constipa- 
tion — all, or some of them, are nearly always to be found ; 
so that if a man suddenly feigns insanity, we look for these 
and for the symptoms of recent and acute mental disorder. 
If the insanity simulated is that of quiet and apparently 



FEIGNED INSANITY. 391 

chronic monomania or dementia, we shall know that these 
forms do not come on suddenly, and that there must have 
been a previous stage. 

Various plans have been advocated for the purpose of 
making the simulator confess the imposture, and give up his 
acting. Speaking in his presence of remedies which will 
probably have to be used, such as the actual cautery, and 
the sight of its preparation, may frighten some pretenders. 
The sight of the stomach-pump may make a man take his 
food ; but then a lunatic will take it for the same reason. 
In accordance with the truth, in vino Veritas, feigned insanity 
has, it is said, been detected by the opening influence of an 
intoxicating amount of wine ; this, however, is hardly appli- 
cable to the inmates of jails. Little is to be gained from 
drugs, unless it be from a good dose of tartar emetic, which 
may make a man confess rather than have another. This, 
of course, is to be given only when our mind is made up con- 
cerning the case, and when we want to put an end to the 
play. A cold shower bath may cure another, but probably 
nothing is so efficacious as the application of a galvanic bat- 
tery. In a very interesting paper, Dr. David Nicolson, one 
of the medical officers at Portland, has related the valuable 
aid derived from this instrument. His remarks on feigned 
insanity among prisoners are well worth perusal. 1 When 
you are convinced that a person is shamming, you will prob- 
ably effect a rapid cure by a few turns of the machine, or a 
repetition of it twice a day for a few days. 

There are cases on record where skilful cheats have de- 
ceived for a long period even alienist physicians, but such 
are rare. Consider if there is a strong motive for feigning 
insanity : if there has never been anything of the kind prior 
to the motive arising, and if the insanity is violent and acute 

1 Journal of Mental Science. January, 1870. 



392 FEIGNED INSANITY. 

in character, we may reasonably suspect it, and close obser- 
vation will generally leave no doubt of the deception. 

I alluded a minute ago to a belief not altogether uncom- 
Theodorof moil, that the insane possess a peculiar odor, and 
the insane. ^at i nsan ity may be detected by the nose. I will 
not relate to you the various opinions and modifications of 
opinion on the subject. It is one of those matters which 
can hardly be brought to a definite test, for the sense of 
smell is altogether subjective, and a preconceived notion may 
go far to help a person to discover an odor. Doubtless many 
lunatics smell offensively. I have already told you that in 
acute mania there is often an intolerable effluvium, especially 
from women. Many patients can with difficulty, even in a 
chronic state, be kept sweet, and, if very stout, their odor 
may be perceptible enough. Many of the poorer classes wear 
their clothes a long time, and thus acquire a stale and dis- 
agreeable smell. But that there is a smell peculiar to the 
insane, which emanates from every insane person, I myself 
have failed to discover. It may be that my sense of smell 
is not so acute as that of others, though of this I am unaware ; 
but certainly I believe that I have seen insane ladies and gen- 
tlemen who, washing and dressing like other people, were as 
free from smell as the sane who sat with them at table un- 
conscious of their presence. Unfortunately, we are not likely 
to advance beyond mere theories and opinions on the subject, 
and my own opinion is all that I will advance at the present 
time. 



LECTURE XIX. 

The Law of Lunacy — Private Patients — Order and Certificates — Single 
Patients — Notice of Discbarge or Death — Leave of Absence — Order 
of Transfer — Pauper Patients — The Property of Patients — Commis- 
sion of Lunacy. 

It now becomes my duty to tell you something about the 
legal methods of dealing with persons of unsound mind. 
Legislation has again and again, during five hundred } 7 ears, 
regulated the manner in which the persons and property of 
such people are to be cared for ; and although the statutes 
relating to the subject are not less than forty in number, I 
hope to be able to put before you in brief that which it is 
essential for you to remember while practicing your profes- 
sion. And I may as well say at the outset that I am not lec- 
turing for those who have, or are to have, the care and charge 
of an asylum. Any of you who undertake this duty will 
learn the details, legal and medical, by special study. My 
present object is to teach to those who are not specially con- 
cerned with this branch of practice that which they require 
for the purpose of sending a patient to an asylum, attending 
one who does not require the restraint of an asylum, and 
giving evidence before a commission in lunacy, or on other 
occasions when a man's sanity is called in question. 
/ The subject naturally divides itself into two parts, one 
which relates to the person, the other to the property of a 
lunatic; and the former may be subdivided into one portion 
relating to the person of private lunatics, and that which is 



394 THE LAW OF LUNACY. 

concerned only with the custody of paupers. I therefore 
shall speak of it under these heads. \ 

1. The care and custody or private lunatics. 

2. The care and custody of pauper lunatics. 
II. The care of the property of lunatics. 

Here I would remark that a man does not necessarily come 

under the cognizance of the lunacy laws because he 

iltVdo nTt happens to be a lunatic. He may be a lunatic for 

affect an years, and may be tended and restrained in his own 

lunatics. •' J 

house, or in that of a relative or friend, provided 
that his own friends or relations take care of him, and take 
care of him properly. It is the common law of the land that 
a man's friends may restrain him from harm, or protect him, 
if he is unable to protect himself. But if the lunatic is not 
taken care of by his own friends^ or if they neglect him, and 
he is found to be wandering at large or improperly confined or 
maintained, then the Lunacy Acts reach him, the Lord Chan- 
cellor or Home Secretary may order him to be visited in the 
friends' or his own house, and necessary steps to be taken 
for his amelioration. 

The Lunacy Acts define with tolerable accuracy the per- 
sons who may take care of lunatics without legal supervision. 
They must be persons "who derive no profit from the charge." 
Any one deriving profit, whether as proprietor of the house 
or lodging, or as companion, nurse, or attendant, must com- 
ply with the statutes I am about to describe. 

There is, however, one exception to this. The committee 
of a person found lunatic by inquisition may take charge of 
such person, or may commit him to the charge of another, 
without medical certificates, upon his own order, having an- 
nexed to it an office-copy of his appointment. 

With these exceptions — viz., the care of a patient by his 
Documents own relatives or friends, or his own committee or 
necessary for committee's agent — all private lunatics are to be 

restraining a o i 

lunatic. restrained and kept only after the due execution 



THE LAW OF LUNACY. 



395 



The "order. 



of three legal documents, which are called the " Order and 
Medical Certificates." Although you, as medical men, are 
chiefly concerned with the latter, it is right that you should 
also be familiar with the "order," that you may be able to 
instruct the friends of a patient. 

Here is the order in the statutory form. Generally speak- 
ing, we fill up printed forms, but the whole may 
be in writing if no printed form is at hand. 

ORDER FOR THE RECEPTION OF A PRIYATE PATIENT. 

I, the undersigned, hereby request you to receive John Jones, 
whom I last saw at 20 Smith Street, Paddington, on the tiuenty- 
first March, 1870, (a) a (b) person of unsound mind, as a patient 
into your house. 

Subjoined is a statement respecting the said John Jones. 
Signed, Name, Mary Jones. 

Occupation (if any), 

Place of abode, 20 Smith Street, Paddington. 
Degree of Relationship (if any), ^ 

or other circumstances of con- >• Wife. 
nection with the Patient, ) 

Dated this twenty-first day of March, one thousand eight 
hundred and seventy. 

To Robert Brown, Esq.,(c) (c) Proprietor or 

Proprietor, (d ) Bath House Asylum. superintendent of. 

A ,v ' ° (d) Describing 

the house or hos- 
pital by situation 
and name. 



(a) Within one 
month previous to 
the date of the 
order. 

(b) Lunatic, or 
an idiot, or a per- 
son of unsound 
mind. 



I have here filled up the order with the name of an im- 
aginary patient, John Jones, the other names being, of course, 
equally fictitious. Now, observe that the person signing the 
order must have seen the patient within a calendar month. 
This is a recent and most proper regulation. Formerly, a 
person might sign an order for the reception of one whom 
he had never seen in his life ; but now he must have seen 
him within a month, must state where he saw him last, and 
affirm that he is of unsound mind. In the marginal notes 
you will see that the patient may be described as a lunatic, 



396 THE LAW OF LUNACY. 

idiot, or person of unsound mind. One of these he must be 
called, and it is usual to adopt the last as the least painful 
to friends, and, at the same time, most comprehensive. " Sub- 
joined is a statement." This must accompany the order, and 
to it I shall come immediately. Who may sign the order, and 

who may not ? I suppose, in my imaginary case, 
may not sign that the wife signs it. It should, in my opinion, 

be signed by the nearest relative; but frequently 
there is a great objection to so doing on the part of relatives, 
and the statute allows any one to sign who can show any 
sort of reason for interfering, as a friend, a magistrate, or the 
minister of the parish. He or she must, however, have seen 
the patient within the month, and this the date at the bottom 
will indicate. But certain people may not sign the order. 
First, no person may sign who receives any percentage on,, 
or is otherwise interested in, the payments to be made by, or 
on account of, any patient received into an asylum or other 
house. Secondly, no one can sign the order who is the med- 
ical attendant, or the proprietor, of the asylum into which 
the patient is to go. Thirdly, no one can sign who is the 
father, brother, son, partner, or assistant, of either of the 
medical men who sign the certificates, or who himself has 
signed one of the certificates. The order must be directed 
to the person under whose care the patient is to be placed, 
whether it be the owner of a private house or lodging, or 
the owner or superintendent of a private lunatic asylum or 
hospital. 

This order, you are to recollect, will authorize the recep- 
tion of a patient during one calendar month from its date, 
Duration of an d no longer. If a month has expired, a fresh 
the "order." or d er w [\\ b e necessary. 1 

Underneath the order on the printed form is placed the 
The "state- " Statement," which I will fill up with supposed 
ment." particulars. 

i 25 and 26 Yict. cap. 3, sec. 23. 



THE LAW OF LUNACY. 



397 



STATEMENT. 

If any particulars in this statement he not known, the fact to be so stated. 



Name of patient, with christian name at } 
length, } 

Sex and age 

Married, single, or widowed, . 

Condition of life and previous occupation 
(if any), 

Eeligious persuasion, so far as known, 

Previous place of abode, . 

Whether first attack, 

Age (if known) on first attack, 

When and where previously under care 
and treatment, .... 

Duration of existing attack, 

Supposed cause, .... 

Whether subject to epilepsy, . 

Whether suicidal, .... 

Whether dangerous to others, . 

Whether found lunatic by inquisition 
and date of commission or order for in 
quisition, 

Special circumstances (if any) preventing 
the patient being examined before ad 
mission, separately by two medical 
practitioners, .... 

Name and address of relative to whom 
notice of death to be sent, 

Signed, Name, (e) Mary Jones 

Occupation (if any), 
Place of Abode, 

Degree of Relationship (if any), or other ] 
circumstances of connection with the 
Patient. 



John Jones. 

Male, 35. 
Married. 

Cleric. 

Church of England. 

20 Smith Street, Paddington. 

Second. 

Thirty. 

Bath House Asylum, in 1865. 

Three weeks. 
Unknown. 

No. 
Yes. 

No. 

No. 



None. 

Mary Jones, 20 Smith Street, 
Paddington, W. 

(e) Where the 
person who signs 
the statement is 
not the person 
who signs the or- 
der, the following 
particulars con- 
cerning the per- 
son signing the 
statement are to 
he added. 



This statement, which is the appendix, as it were, to the 
order, needs little explanation. It is a statement of the 
facts of the case for the guidance of the proprietor of the 
asylum, and for the information of the Commissioners in 
Lunacy. As in the order, the name of the patient must be 



398 THE LAW OF LUNACY. 

stated in full, christian and surname, and every other detail 
must be filled up in some way. No space must be left blank. 
There are certain points on which friends are very reluctant 
to give accurate information, and yet it is important that we 
should have it. They are very apt to give the duration of 
the existing attack as being very short, when it may turn 
out on inquiry that the patient has been insane for a long 
period, though possibly only dangerous or excited during a 
few weeks or days. Then we rarely get the true cause as- 
signed. Frequently this is hereditary transmission — a fact 
which friends are most loath to mention. And they do not 
like to describe a patient as suicidal or dangerous, and yet it 
is of great importance to those who are to have the charge 
that this should be stated, and if there be any doubt, it is 
better to state the suspicion than to give a direct negative to 
the question. With regard to the last question but one, 
"special circumstances, &c," I must say a word. Inasmuch 
as it is often very difficult for a medical man to gain access 
to a patient, and it may be of the utmost consequence that 
such a patient should be at once deprived of the power of 
doing harm to himself or others, there is a clause in the Act 
— 16 and 17 Vict., c. 96, sec. 5 — which provides that "any 
person (not a pauper) may, under special circumstances pre- 
venting the examination of such person by two medical prac- 
titioners, be received as a lunatic into any house or hospital, 
upon such 'order' as aforesaid, and with the certificate of 
one physician, surgeon, or apothecary alone, provided that 
the statement accompanying such order set forth the special 
circumstances which prevent the examination of such person 
by two medical practitioners ; but in every case two other 
such certificates shall, within three clear days after his re- 
ception into such house or hospital, be signed by two other 
persons, each of whom shall be a physician, surgeon, or 
apothecary, not in partnership with or an assistant to the 
other, or the physician, surgeon, or apothecary, who signed 



THE LAW OF LUNACY. 399 

the certificate on which the patient was received, and not 
connected with such house or hospital, and shall within such 
time and separately from the other of them have personally 
examined the person so received as a lunatic." 

Such is the meaning of the question commencing with the 
words "special circumstances." 

The statement is commonly, but not necessarily, signed by 
the person who signs the order. It may be signed by any 
one having the knowledge requisite, and he must state his 
relationship or connection after the signature. 

We now pass to that which more immediately concerns 
ourselves, viz., the medical certificates. 

And first, who may and who may not sign these? Any 
physician, surgeon, or apothecary may sign a certifi- The two 
cate, if he be a person registered under the Medical medical cer- 

tificates. 

Act passed in the session 21 and 22 Victoria, cap. 

90. Not only must he be legally qualified, he must also be 

registered. This is not generally known; but the reception 

of a certificate from a non-registered practitioner would, in 

my opinion, lay the proprietor of an asylum open to the 

charge of illegally receiving. 

i Certain medical men, however, are precluded from signing 

the certificates. 

1. The two medical men must not be profes- Wh0ina , 0l . 
sionally connected, must not be in partnership, nor ^ not BigB 
may one be the assistant of the other. 

2. Neither of them must be the proprietor of the house or 
asylum into which the patient is to be received, nor must he 
receive any percentage on the payments to be made for the 
patient, nor must he be the medical attendant after recep- 
tion of such patient, whether in a private house or an asylum. 

3. No medical man who, or whose father, brother, son, 
partner, or assistant, is wholly or partly the proprietor of, or 
the regular professional attendant in, a licensed asylum or 



400 THE LAW OF LUNACY. 

hospital, shall sign a certificate for the reception of a patient 
into such house or hospital. 

4. No medical man who, or whose father, brother, son, 
partner, or assistant, shall sign the "order" already spoken 
of, shall sign any certificate for the reception of the same 
patient. 

Thus, you observe the various persons — the person sign- 
ing the order, and those signing the certificates — are to be 
entirely independent one of another, and all three are to be 
independent and unconnected with the proprietor of the 
asylum, or the medical attendant of the patient, if he is n'ot 
in an asylum. So the co-operation of four independent per- 
sons, of whom three must be medical men, is requisite for. 
the restraining of any one under the Lunacy Acts, and each 
of the two medical men who are to sign the certificates must 
examine the patient separately. This you must recollect, 
because in all probability it will happen that you will be 
called to meet another practitioner to consult with him as 
to the propriety of placing some one under legal restraint. 
Although you together make an examination for the purpose 
of consultation, you must again visit and question the indi- 
vidual separately, and, repeating the examination, you must 
elicit that which you are about to write down in your certifi- 
cate. Otherwise, if at any future time the alleged lunatic 
were to bring an action against the proprietor of the asylum 
for false imprisonment, the certificates would be invalidated 
by neglect of this rule. 

I now pass to the consideration of the form of the medical 
certificates, one of which I will fill up, as I filled up the 
order, with imaginary details. 



THE LAW OF LUNACY. 



401 



MEDICAL CEKTIFICATE. 

I, the undersigned, being a (a) Fellow of the Boyal College 
of Surgeons of England, and being in actual practice as a 
(6) Surgeon, hereby certify that I, on the twentieth day of 
March, 1870, at (c) 20 Smith Street, Paddington, in the 
county of Middlesex, separately from any other medical 
practitioner, personally examined John Jones, of (d) 20 
Smith Street, Paddington, clerk, and that the said John 
Jones is a (e) person of unsound mind, and a proper person 
to be taken charge of and detained under care and treat- 
ment, and that I have formed this opinion upon the follow- 
ing grounds, viz. : 

1. Facts indicating insanity observed by myself. (/) He 
is under a delusion that he has committed some unpardonable 
sin, that he is Antichrist, and that his name is mentioned in 
all the newspjapjers. His appearance denotes great agitation 
and depression. 

2. Other facts (if any) indicating insanity communicated 
to me by others, (g) I am informed by his brother, Bobert 
Jones, that he has attempted to jump into the river, and out 
of window. 

Signed, Name, William Green. 
Place of Abode, 10 Bichmond Street, Paddington. 

Dated this twenty-first day of March, one thousand eight 
hundred and seventy. 



(a) Set forth the 
qualification enti- 
tling the person cer- 
tifying to practice as 
a physician, surgeon, 
or apothecary, ex. 
gra. .-—Fellow of the 
Royal College of 
Physicians in Lon- 
don, Licentiate of the 
Apothecaries' Com- 
pany, or as the case 
may he. 

(6) Physician, sur- 
geon, or apothecary, 
as the case may be. 

(c) Here insert the 
street and number of 
the house (if any), 
or other like particu- 
lars. 

(d) Insert residence 
and profession or oc- 
cupation (if any), of 
the patient. 

(e) Lunatic, or an 
idiot, or a person of 
unsound mind. 

(/) Here state the 
facts. 

(g) Here state the 
information, and 
from whom. 



Now, if you consider this form of medical certificate, you 
will notice that, according to the directions appended in the 
margin, you are first of all to state your legal qualification. 
Not merely are you to say that you are a physician or sur- 
geon ; you are to give the name of the diploma you hold. 
In addition to this, you must assert that you are in. actual 
practice ; a retired practitioner, or a medical man who has 
given up the profession and is otherwise occupied, cannot 
sign either of the certificates. Then comes the date, and this 
is important. The dates of the certificates are quite different 
from those of the order. The order may be signed and dated 
by any one who has seen the patient within a month, and it 
is valid for a month from the signing thereof. But the medical 



20 



402 THE LAW OF LUNACY. 

certificate is only valid for seven days, not from the signing. 
^ „ , but from the examination of the patient. The date 

Duration of L 

medicai f the examination, the first date in the certificate, is 

CGrtiiicntcs 

the important part : within seven days from this the 
reception of the patient must take place, or the certificate 
expires. It may be signed and dated at any time between 
the examination and the reception. The date of the day of 
the month and the j^ear must be given, and also the place of 
examination. And you are to specify the street and number 
of the house, if it has one, as well as the county. Also your 
examination of the patient must take place without any 
medical man being present, as I have already explained to 
}'Ou. Other people may be present, but they must not be 
medical men practicing. The names, christian and sur- 
name, of the patient must be written at length, together 
with his residence, profession, or occupation. You then 
affirm that the said patient is one of three things — a luna- 
tic, idiot, or person of unsound mind; and, as I said in the 
case of the order, it is better to use the last expression, 
which comprises every variety. You also affirm — and this, 
too, is important — not only that the individual is of un- 
sound mind, but that he is " a proper person to be taken 
charge of and detained under care and treatment;" in other 
words, to be taken care of as a lunatic under certificates of 
lunacy. There may be many patients afflicted with un- 
soundness of mind, temporary or other, for whom we might 
hesitate or refuse to sign certificates of lunacy. Formerly 
the medical man merely stated his opinion that the patient 
was of unsound mind, without giving reasons, and upon 
such a certificate the patient was received. The same prac- 
tice still continues in Ireland; but in England and Scotland 
you are obliged to state your reasons for coming to such a 
conclusion; and the Commissioners will reject the certifi- 
cate and release the patient if they do not consider the rea- 
sons strong enough. Now, the reasons are divided in the 



THE LAW OF LUNACY. 403 

form into two parts — the facts observed by yourselves, and 
those communicated by others ; and I need not tell The 
you that those observed by yourselves are the most indicating 
important, the others being necessarily hearsay re- 
ports, which frequently you may have reason to .disbelieve. 
Now, these facts are supposed to be observed by you on the 
day of examination, the day mentioned as the date, and 
when they consist of the result of conversation carried on upon 
that day, there can be no doubt about the matter. When, 
however, your opinion is based not upon a particular de- 
lusion, but upon the general conduct of an individual, there 
is often great difficulty in getting enough on one particular 
day to warrant your signing a certificate. And the Com- 
missioners in Lunacy insist on this being done. In their 
Fifteenth Report (1861) they say: "It would, of course, be 
impossible that any examining medical man should exclude 
from his consideration facts known to him of the antecedents 
of the patient, immediate or remote; these are entitled to 
their full influence; but the legislature has been careful to 
guard against such facts exercising undue influence in the 
certificate he is called on to give, by requiring that this cer- 
tificate shall be directly deducible from examination on a par- 
ticular day and at a specified place ; and that the opinion ex- 
pressed therein as having been formed on such particular day 
shall be set forth as the result of his having observed at that 
time in the person under examination some specific fact indi- 
cating insanity." 

You will, therefore, have to connect that which you may 
have observed previously with what you observe on the par- 
ticular day. If a patient justifies his past conduct, and de- 
fends it in an insane manner, you may elicit sufficient for 
your purpose ; or, without asserting delusions, he may admit 
that he has entertained them previously, or otherwise indi- 
cate that he has not given them up. Frequently, when you 
anticipate that you will have to examine a patient for a cer- 
tificate, and have reason to think that he will deny his be- 



404 THE LAW OF LUNACY. 

liefs, it is as well not to subject him to any cross-examination 
upon them till the actual day arrives. But I shall have 
something to say concerning the examination of patients 
subsequently : here I am only speaking of the requisite 
formalities. 

It is not necessary that any facts communicated by others 
should be inserted. Where those observed bv your- 

Facts com- . J J 

municated selves are plain and* unmistakable, it rather weakens 
than strengthens a certificate to supplement them 
with others received on hearsay. But frequently that which 
you observe is explained and illustrated by what the patient 
has said to others ; and acts committed by him, acts of at- 
tempted homicide, suicide, or other violence, may not have 
been witnessed by you, yet may be valuable indications of 
insanity. 

Two certificates complete the formalities requisite for 
placing a patient under restraint. Each must be the inde- 
pendent opinion of a registered practitioner, who, in signing 
this legal document, does so under grave responsibilities. If 
he does it negligently or fraudulently, he is liable to an 
action at law, and to be mulcted in heavy damages. Upon 
such order and medical certificates, a proprietor or superin- 
tendent of an asylum may receive a person as a lunatic, 
co ies of pleading them in justification ; but he must send a 
order and cer- copy of them to the Commissioners in Lunacy 

tificates to be. . 

sent to com- within twenty-four hours; and then, after the ex- 

missioners. ,. « . i -> ii^xi 

piration 01 two clear days, and before the expira- 
tion of seven days, he also transmits to the Commissioners a 
" statement," containing his own observations upon 

Also a state- 

ment of the mental and bodily state of the patient. The 
same thing is done by the proprietor, if the patient 
is removed, not to an asylum, but to the house of a private 
individual, becoming what is called a " single patient." 

You will have noticed in the newspapers reports of prose- 
" single cutions, instituted by the Commissioners in Lunacy, 
against various persons, for wrongfully receiving 



patients.' 



THE LAW OF LUNACY. 



405 



and taking care of people of unsound mind ; and, from the 
phraseology adopted, you may think, as many do, that they 
were prosecuted for receiving these patients witliout a license. 
But this is not so. No license is required for the reception of 
one patient. When two are received, then a license becomes 
necessary. What is requisite is that these single patients 
should be received upon an "order" and two certificates, just 
as if they went to an asylum, and that copies should be sent 
to the Commissioners, thus registering the patient on their 
records. 

As you may have occasion to send patients to reside in this 
way with a family, and may wish to attend them while there, 
I will briefly describe the regulations to be observed. You 
wish to send one to the house of some private individual, 
male or female. The order and certificates are procured in 
the usual way, and copies of them are to be sent by the pro- 
prietor of the house to the Commissioners in Lunacy within 
twenty-four hours of the admission of the patient, together 
with a notice of the admission signed by the said proprietor. 
If you are to be the medical attendant, you must not sign either 
of the certificates. After two clear days, and before the ex- 
piration of seven days, you will send to the Commissioners a 
"statement" of the mental and bodily condition of the pa- 
tient. Then once a fortnight at least you will enter in a book, 
to be kept at the house for the inspection of the Commis- 
sioners, an account of the patient under the following heads : 



Date. 


Mental 

State and 
Progress. 


Bodily 
Health and 

Condition. 


Restraint or Seclusion 

since last Entry. #hen 

and how long. " By what 

means and for what 

reason. 


Visits of 
Friends. 


state of 
House, Bed, 

and 
Bedding, Ac. 















This is called the "Medical Visitation Book," which will 



406 THE LAW OF LUNACY. 

be inspected and signed by the Commissioners when they 
visit the patient. When the patient leaves, a u Notice of 
Notice of Discharge" must be sent to the Commissioners by 
discharge, foe proprietor in the following form : 

FORM OF NOTICE OF DISCHARGE. 

I hereby give you notice, that a single patient, 

received into this (a) on the day of 18 , 

was discharged therefrom (6) by the authority of 

day of 18 . 

Signed, 

(c) ■ - 



Dated this day of one thousand eight hundred and 

seventy 

To the 



(a) House. 

(ft) Recovered, or relieved, or not improved. 

(c) Superintendent or proprietor of house or hospital at . 

If he dies, a " Notice of Death," signed by the medical at- 
Noticeof tendant, must be sent to the Commissioners and also 
death. f. Q fa e Q oroner f t'he district, who may hold an in- 
quest if he thinks fit. There is a special form for the notice 
of death. 

NOTICE OF DEATH. 

I hereby give you notice, that a single patient, 

received into this (a) on the day of 18 , died 

therein on the day of 18 ; and I further certify, that 

was present at the death of the said 
and that the apparent cause of death of the said (6) 

was 

Signed, 

W 



Dated this day of one thousand eight hundred and 

seventy 

To the Commissioners in Lunacy. 

(a) House or hospital. 

(6) As ascertained by post-mortem examination, if so. 

(c) Medical attendant of 



THE LAW OF LUNACY. 407 

I give you the forms of this and of the notice of discharge. 

Blank forms like the above may be purchased, but it is 
not absolutely necessary that the order and other documents 
should be on a printed form. The whole may be in manu- 
script if a printed form is not procurable, provided that the 
wording is the same. 

If it is thought advisable to send the patient for change of 
air to the seaside or elsewhere, or to allow him to go « L eaveof 
home upon trial, " Leave of Absence " may be ob- Absence " 
tained from the Commissioners. 

OFFICE OF COMMISSIONERS IN LUNACY, 

19 Whitehall Place, S. W., 

18 . 
By virtue of the power vested in us by the 86th section of the Act 8 and 9 
Vict. c. 100, we hereby signify our consent to the removal under proper con- 
trol, of a certified patient in House, to 
for the period of calendar month from 

Commissioners 
in Lunacy. 
To 

Note. — In forwarding "the approval in •writing" required by the above section, it should be stated, 
•whether it is "of the person who signed the order," or "of the person who made the last payment." 

If it is necessary to remove him from one place of residence 
to another, or from one asylum to another, this may be done 
by obtaining an " Order of Transfer" from the Com- « rderof 
missioners, in which case fresh certificates will not Transfer " 
be required. 

TRANSFER OF PRIVATE PATIENT. 
CONSENT. 

We, the undersigned, Commissioners in Lunacy, hereby consent to the re- 
moval, on or before the day of 18 , of a private 
patient in House 

Given under our hands this day of 

in the year of our Lord, one thousand eight hundred and 

"^ Commissioners 
j in Lunacy. 



408 THE LAW OF LUNACY. 



ORDER. 

I* the undersigned, having authority to discharge a private 

patient in House, hereby order and direct that the said 

be removed therefrom to House 

Given under my hand this* day of in the year of our 

Lord one thousand eight hundred and 
Signed, 
Place of abode, 

Note. — This order must be signed and dated subsequently to the consent of the Commissioners : 
and it must be signed by — 

1. The person who signed the order for the patient's admission: 

2. If such person be incapable (by reason of insanity, or absence from England, or 
otherwise), or if he be dead, then by the husband or wife of the patient: 

3. If there be no husband or wife, then by the patient's father: 

4. If there be no father, then by the patient's mother : 

5. If there be no father or mother, then by any one of the patient's nearest of kin : 
or by the person who made the last payment on the patient's account. 

In cases of Chancery patients — The Committee of the person. 



Generally 



If the patient escapes, he may be recaptured within four- 
Escape and teen days upon the original order and certificates: 
recovery. jf f our t een ^ a y S have elapsed, a fresh order and cer- 
tificates must be obtained. Notice of the escape and recap- 
ture must be sent to the Commissioners. If not recaptured, 
notice of the escape must be sent within two clear days. 

All these enactments apply equally to private patients in 
asylums, and to single patients. 

I will now say a few words as to the method of proceeding 
Pauper when we desire to place a pauper in an asylum. Of 
patients. ^ Je management of public asylums I say nothing, but 
it may fall to your lot to have to send thither poor people 
who have been under your care. 

The law enacts that the medical officer of a poor-law 
district, on becoming aware of a lunatic, shall give notice 
thereof to the relieving officer, or, if there be not one, to the 
overseer. In the same way any person may give notice of 
the same to the relieving officer or overseer. The latter is 
in turn to give notice to a justice of the peace of. the county 
or borough, who within three days shall cause the lunatic to 
be brought before him, or shall visit him at his house, and 
shall examine him, with the aid of a medical man. If the 



THE LAW OF LUNACY. 409 

latter gives a medical certificate, and the justice is satisfied 
that the pauper is a lunatic, and a proper person to be taken 
charge of and detained under care and treatment, he shall 
make an order for his reception into an asylum. If two 
medical certificates are given, one by the medical officer and 
a second by any other medical man, the justice must make 
the order without any option. 

If the pauper cannot be taken before a justice or be visited 
by him, he may be visited by an officiating clergyman, to- 
gether with the relieving officer (or overseer), and their joint 
order may be given for his removal, after the medical cer- 
tificate or certificates are signed. The medical certificate is 
in precisely the same form as that I have already given. It 
must not be signed, however, by any medical man who is 
the medical officer of the asylum, nor by any one whose 
father, brother, son, partner, or assistant shall sign the order. 

If the relieving officer cannot at once take the lunatic to 
the asylum, he may take him to the workhouse, and in point 
of fact a great number of patients are taken there first : but 
it is enacted that "No person shall be detained in any work- 
house, being a lunatic, or alleged lunatic, beyond the period 
of fourteen days, unless in the opinion, given in writing, of 
the medical officer of the union or parish to which the work- 
house belongs, such person is a proper person to be kept in a 
workhouse, nor unless the accommodation in the workhouse 
is sufficient for his reception : and any person detained in a 
workhouse in contravention of this section shall be deemed 
to be a proper person to be sent to an asylum within the 
meaning of section sixty-seven of the Lunacy Act, chapter 
97 ; and in the event of any person being detained in a work- 
house in contravention of this section, the medical officer 
shall, for all the purposes of the Lunacy Act, cap. 97, be 
deemed to have knowledge that a pauper resident within his 
district is a lunatic and a proper person to be sent to an 
asylum ; and it shall be his duty to act accordingly, and 



410 THE LAW OF LUNACY 

further to sign such certificate with a view to more certainly 
securing the reception into an asylum of such pauper lunatic 
as aforesaid."— (25 & 26 Vict. c. 3, sec. 20.) 

This section enacts that any medical officer having knowl- 
edge of a lunatic being in his district, being a proper person 
to be sent to an asylum, shall give notice of it in writing to 
the relieving officer or overseer. — (Vide ante, p. 395.) 

The foregoing remarks apply to pauper patients resident 
wandering m a parish or district. But patients are often found 
lunatics. a £ } ar g e — wandering lunatics, as they are called — and 
the law deals with them in this capacity. It is enacted (16 
&17 Vict. c. 97, sec. 68), that every constable, relieving 
officer, or overseer, who shall have knowledge that any person 
wandering at large within the parish is deemed to be a luna- 
tic, shall immediately apprehend and take such person be- 
fore a justice. The justice, calling to his aid a medical man 
and obtaining from him a medical certificate, may make an 
order for the lunatic's reception into an asylum or hospital. 
Or the justice may act on his own knowledge, and may ex- 
amine the lunatic at his own abode or elsewhere. 

This is to be done whether the patient is a pauper or not. 
Patients may be found wandering at large and be taken care 
of in this way till their friends can be communicated with, 
or they may be taken to an asylum, if paupers, and thence 
transferred to the asylum of their own parish. But in this 
manner they are to be dealt with according to the law. 

There are other patients for whose amelioration the law 
Lunatics makes provision. These are people not wandering 
improperly ^ large, but ill treated or neglected by their rela- 

treated by c 7 ° « / 

friends. tions or friends. Not unfrequently do we read in 
the newspapers of lunatics found caged in cellars, attics, or 
outhouses, and more or less neglected or cruelly treated. 
Or, short of this, a lunatic may be allowed by his relatives to 
remain in his own house in a state in which he is danger- 
ous to himself or others. Here the enactment is in some 



THE LAW OF LUNACY. 411 

respects similar to the last mentioned. The constable, re- 
lieving officer, or overseer of any parish, having knowledge 
of there being such a lunatic not under proper care and con- 
trol, or being cruelly treated or neglected by any relative or 
other person having the care or charge of him, shall give in- 
formation on oath within three days to a justice of the peace, 
who shall visit and examine such person, or direct some 
medical man to visit and examine him ; and shall then re- 
quire any constable or relieving officer to bring the lunatic 
before any two justices of the county or borough, and they 
shall call upon a medical man to examine him, and, with 
his certificate, send him to an asylum. They may, however, 
suspend the removal for a period not exceeding fourteen 
days; and they may hand the patient over to his friends, if 
satisfied by them that he will be properly taken care of. 

You are not to forget, however, that it is lawful for any 
one to restrain a lunatic who is dangerous to him- „ 

° Dangerous 

self or others, by virtue of the common law, apart lunatics may 

n it mi-ii -i'-it be restrained 

from the lunacy statutes, lhis has been decided under the 
more than once. In Scott v. Wakem, an action of c 
trespass was brought against a medical man for placing the 
plaintiff under restraint while in a state of delirium tremens; 
and Baron Bramwell ruled that a medical man may justify 
measures necessary to restrain a dangerous lunatic. The 
same opinion was held by Chief Justice Cockburn, in Symm 
v. Fraser and another, in 18C3. Here Mrs. Symm, a widow, 
had been restrained while in a state of delirium tremens. 
It is done, in fact, constantly : certificates of lunacy are not 
signed for patients whose malady only lasts for a few days. 
We use the measures necessary for their safe custody, as we 
should for those delirious from fever or other diseases. And 
in the case of dangerous lunatics, you will recollect that you 
are justified in restraining them by force from doing mischief, 
till the order and certificates necessary for placing them in 



412 THE LAW OF LUNACY. 

an asylum are signed. Do not be timid in taking such steps. 
Do not, as is so often the case, let the patient go on till some- 
thing dreadful occurs. The bench of judges will take care 
that you are held blameless in such a case, whatever preju- 
diced juries may think. The Chief Justice, in the latter of 
the actions I have named, desired the jury "to consider the 
case not only with reference to the interests of the individ- 
uals committed to the care of medical men, but also with a 
view to their interests in another sense — taking care not to 
impair or neutralize the energy and usefulness of medical 
assistance, by exposing medical men unjustly to vexatious 
and harassing actions." 

There is one other legal procedure on which I must say 
something. Hitherto I have been speaking of the 

Of the prop- ° _ . 

ertyof legal methods of restraining the person of a lunatic, 

patients. . _^ ' 

private or pauper. .But the law, by another pro- 
cess, makes provision for the proper protection of the prop- 
erty of a patient. 

In old times the King was held to be the natural guardian 
of idiots and lunatics, and committed the care of them to 
whom he chose ; but now the Lord Chancellor is directed by 
the Crown to perform this office, and such people become 
wards of the Court of Chancery. There is a numerous array 
of statutes relating to " Chancery lunatics," as they are called 
— statutes which have grown up alongside of those I have 
already mentioned, and which in some respects clash with 
them. There is a separate Board of Commissioners to look 
after such patients, and the consequence is that in many 
details confusion exists. 

For, although a patient may have been for twenty years 
a certified patient in an asylum, visited regularly by the 
Board of Commissioners in Lunacy, at the head of which 
Board is, nominally, the Lord Chancellor, yet so far as his 
property is concerned, the said patient is considered of sound 



THE LAW OF LUNACY. 413 

mind ; and to deal with it on his behalf a commission must 
be issued by the Lord Chancellor to try whether commission 
he be of unsound mind — a fact which may have oflunac y- 
been known to one Board of Commissioners for a long period. 
Not to go into details which do not concern you, I may 
say, that the present practice is for some one or more persons 
interested in the patient to petition the Lords Justices, to 
direct that an inquisition shall be held as to the state of 
mind of the said patient. This petition must be accompanied 
by affidavits of the mental condition, and you may be called 
upon to give such an affidavit. The patient must have notice 
given him of the presentation of the petition, and, if he 
chooses, he may, within seven days of such notice, demand 
a jury. If the Lords Justices direct an inquiry, it is held, 
generally speaking, by one of the Masters in Lunacy. But 
if the Lord Chancellor think fit, he may direct the issue to 
be tried in one of the Superior Courts of common law. When 
the property of the alleged lunatic does not exceed in value 
the sum of one thousand pounds, a commission of lunacy 
may be avoided. By the Act 25 and 26 Vict. c. 86, sec. 12, 
in order that the property of insane persons, when of small 
amount, may be applied for their benefit in a summary and 
inexpensive manner, it is enacted as follows : " Where, by the 
report of one of the Masters in Lunacy or of the Commis- 
sioners in Lunacy, or by affidavit or otherwise, it is estab- 
lished to the satisfaction of the Lord Chancellor that any 
person is of unsound mind and incapable of managing his 
affairs, and that his property does not exceed one thousand 
pounds in value, or that the income thereof does not exceed 
fifty pounds per annum, the Lord Chancellor may, without 
directing any inquiry under a commission of lunacy, make 
such order as he may consider expedient for the purpose of 
rendering the property of such person, or the income thereof, 
available for his maintenance or benefit, or for carrying on 
his trade or business : provided, nevertheless, that the alleged 



414 THE LAW OF LUNACY. 

insane person shall have such personal notice of the applica- 
tion for such order as aforesaid as the Lord Chancellor shall 
by general order direct." 

The alleged lunatic may demand a jury, and the demand 
must be complied with, unless the Lord Chancellor is satisfied 
by personal examination that the individual is incompetent 
to express or form a wish on the subject. Practically, we 
find that many patients are in this condition : no jury is 
demanded, and then the issue is tried by one of the Masters 
with a jury. 

Whether there is a jury or not, you may have to be ex- 
amined on oath as a witness, and, it may be, cross-examined, 
and it behooves you to form a very clear and accurate concep- 
tion of the opinion you are going to give, and the grounds on 
which you will uphold it. Counsel will try to entrap you 
in every way, and ask you to define insanity, or unsoundness 
of mind. Do not, however, be tempted into discussing any 
abstract questions ; confine yourself to the case before you, 
the state of mind of the alleged lunatic, and that which he 
has said or done. You will be assailed with questions as to 
whether you think this or that act indicative of insanity. 
Such an act may possibly be done by a sane person, but a 
number of such acts may be conclusive as to the insanity of 
any one, or one act may at once stamp the particular indi- 
vidual as insane. 

Your opinion may be asked as to the advisability of hold- 
ing a commission of lunacy, for it is not expedient to take 
this costly step if the patient is likely to recover soon, or to 
die. Solicitors often fancy that a commission of lunacy is to 
be taken out as soon as a patient is put under legal restraint, 
but this is not so. Unless his affairs urgently demand it, 
such a step should be deferred until it can be seen whether 
he is likely to recover in a reasonable time or not. I have 
known a patient nearly well before the commission was held : 
and if he is likely to recover within a few months, it is most 



THE LAW OF LUNACY. 415 

unfair to subject him to the expense and stigma of a com- 
mission, and throw upon him the trouble and cost of super- 
seding it. Your prognosis will be based upon the principles 
enunciated throughout these lectures, which I need not repeat 
here. Time is in this your great auxiliary : though patients 
do recover after years of insanity, they do so but seldom. If 
a patient has been under care and treatment for a twelve- 
month, and does not show manifest signs of real improve- 
ment, his case is sufficiently unfavorable to warrant at all 
events an inquisition. For, as I have said, this may be 
superseded on recovery. The patient will petition the Lord 
Chancellor or Lords Justices to supersede the petition and 
set free himself and his property, and he must support his 
petition by medical affidavits. Here the questions of re- 
covery, or partial recovery, or apparent recovery, will arise, 
and you will recollect what I said on these heads in a former 
lecture. 



LECTURE XX. 

On the Examination of Patients — Two Things to be considered — On 
Gaining Access to a Patient — On Estimating Doubtful Insanity — 
Information to be Sifted — Visit to a Patient — Conversation— Ap- 
pearance — Alleged Delusions — On Patients who have no Delusions — 
On the Examination of Imbeciles and the Demented — Conclusion. 

There remains one subject on which I must say something. 
I have spoken of the legal formalities necessary to be ob- 
served when a man or woman is placed in confinement, and 
have mentioned that you will be called upon to sign medical 
certificates and affidavits of the unsoundness of mind of a 
patient. I propose to say a few words concerning the way 
in which you are to examine such people with a view of test- 
ing their mental condition. Very general must my observa- 
tions be, for it is not possible to lay down rules for the 
performance of such a task with anything like strictness. 
Yet some hints may be useful to those-who are 

Two points . . . , I 

to be kept in quite without experience in the matter! You have 
two things to decide before you sign a certificate : 
first, whether the individual is or is not of unsound mind ; 
secondly, whether he is a fit and proper person to be detained 
under care and treatment! These are distinct questions, and 
it is clear that the legislature, by thus distinguishing them, 
allows to medical men a certain judgment in deciding whether 
or not a person who may be of unsound mind is a proper per- 
son to be detained under care and treatment as a lunatic 
protected or restrained by certificates of lunacy. Many 
patients during acute illnesses may be for a time of unsound 
mind, yet can in no sense be called proper persons to be de- 



ON THE EXAMINATION OF PATIENTS. 417 

tamed as lunatics under care and treatment ; and there may 
be some of feeble mind, jet gentle, harmless, and docile, who 
do not require the protection of the lunacy laws, and are not 
proper persons to be detained. As I have said elsewhere, it 
is not always easy to sign a certificate for a patient concern- 
ing whom we may make a general declaration in an affidavit, 
for the Commissioners in Lunacy insist that all that is alleged 
of the patient shall have been observed on a given day. It 
must not be the outcome of an acquaintance extending over 
some years, and although you have a general opinion that 
the individual is weak-minded or insane, it may be based 
rather on what you have heard than on what you see. 

Concerning the cases of acute disease in which the mind 
is temporarily disordered, little is to be said. You will not 
think of signing certificates here. And in acute insanity, 
where medical assistance is urgently needed, there will be 
little difficulty in appreciating the state of mind, and sign- 
ing a certificate. In these cases the real difficulty expe- 
rienced is more frequently in gaining access to the patient, 
and in engaging him in conversation. This done, his malady 
is revealed, and our end is accomplished. In gain- The inganit 
ing admittance to a patient, our difficulties may ™*y be un- 
come from the patient himself, or from ill-judging access dim- 
or ill-meaning friends, who, because they think 
that all doctors are leagued together to shut every one up in 
a madhouse, or because they have an interest in keeping 
the patient where he is, frustrate the endeavors which per- 
haps his nearest of kin are making for his safety or cure. 
Such persons resist the inspection of the patient, on the plea 
that he is not insane, but only a little excited, and requires 
rest and quiet. They will insist that he is not dangerous, 
and to the best of their ability they will keep him from 
doing anything very outrageous. I suppose that scarcely 
one lunatic has ever been placed in an asylum without some 
of his friends or acquaintances denouncing the sinfulness of 

27 



418 ON THE EXAMINATION OF PATIENTS. 

the proceeding. There is, however, little danger, though 
there may be some difficulty, in visiting such a patient. 
There is more to be apprehended from one who himself 
dreads and avoids you, and who, from a fear that you are 
coming to do him some harm, may resist to the uttermost, 
using murderous weapons. In such a case, it is not possible 
to lay down rules which are universally applicable. You 
have to converse with the patient, to assure yourself of his 
insanity, to sign a certificate. Here, if at all, it may be jus- 
tifiable and necessary for you to resort to stratagem, to invent 
an excuse for an interview, to feign to be other than a doc- 
tor. Such measures are to be avoided when it is possible, 
and they often can be avoided, by tact or by open and straight- 
strata em forward plain speaking. They often lead to great 
not often, difficulties, cause the patient to distrust all about 

though some- . . 

times, neces- him, and give him occasion to make great eom- 
sary ' plaint. But I am not prepared to say they can 

always be dispensed with. If a madman has armed himselt 
with a revolver, and vows that he will not be shut up, and 
if he has, by previous experience, found out that doctors are 
a necessary item in the process, he will be a bold man who 
will go in a strictly professional capacity to sign a certificate. 
One thing is certain, that stratagems are better left alone in 
many cases where friends urge their adoption, especially the 
devices invented by friends, which frequently are so clumsy 
that you may by them be absolutely debarred from having 
the requisite conversation with the alleged lunatic. I have,' 
on arriving at a house, been shown suddenly into a patient's 
room, and introduced to him as some person of whose name, 
occupation, or relationship I was utterly ignorant. If } T ou 
are introduced, not as a doctor, but as a lawyer, man of 
business, or the like, you cannot discuss the patient's health, 
mental or bodily; and questions which you may wish to put 
will sound impertinent or absurd, or will make him suspect 
you to be a doctor in disguise, and he may then refuse to 



ON THE EXAMINATION OF PATIENTS. 419 

hold any conversation with you. In most cases go as a doc- 
tor, and as nothing else. You have then a reason, whether 
he admits it or not, for cross-examining him closely as to his 
bodily and mental health. If stratagem is absolutely neces- 
sary, consider it well beforehand, its probable direction and 
consequences, and be sure that those in league with you play 
their parts faithfully. I am assuming now that the insanity 
of the patient is not doubted, but that conversation with him 
is difficult. The peculiar features of the insanity will furnish 
suggestions for your plan of proceeding. One man has in- 
vented a marvellous scheme for enriching himself and all 
belonging to him. You are come to treat with him for the 
purchase of his patent, or a partnership in his business. 
Another is going to buy houses and lands. You have houses 
and lands to sell. There is little difficulty in dealing with 
such, or in gaining access to them. But if a man is sus- 
picious, fears a conspiracy, and shuts himself up against 
police, bailiffs, or the like, he may resist strenuously all 
efforts to observe him. Such a patient is, however, by the 
nature of his case, fearful; and if. accompanied by sufficient 
assistants, you boldly confront him, he will probably not be 
able to escape entering into conversation with you. If access 
is denied to you, not by the patient, but by others, you must 
consider how the law stands. A man's own house in this coun- 
try is his castle, and, sane or insane, he cannot be removed 
thence except for some good reason, and after lawful proceed- 
ings. The law allows a man's relatives or friends to remove 
him from home for treatment and cure upon a legal order 
and certificate ; but if a husband chooses to keep 

h. n • i • -i • r* l • Access may be 

is insane wile m his own house, or a wile her in- denied not by 

sane husband, no one can order his or her removal P aticnt - but b ^ 

friends. 

unless it can be shown that he or she is improperly 
treated or neglected. Cases of this kind often arise, and the 
lunacy authorities are appealed to and requested to give an 
order for the patient's removal ; but they have not the power, 



420 ON THE EXAMINATION OF PATIENTS. 

and the only method of effecting it is to lay information 
before a justice or justices, as I have mentioned in my last 
lecture. 1 If a patient is properly treated in a relative's house 
or his own, and has medical advice and care, no magistrate 
would feel called on to order his removal, even if other rela- 
tives desired it. But if a person who is no relation takes 
charge of and detains a patient against the wishes of all the 
family in his own or the patient's house, it is probable that 
a magistrate's order might be obtained, and access demanded. 
The Commissioners in Lunacy have little power over patients 
until they are brought under their jurisdiction. When they 
prosecute persons for illegally receiving and detaining pa- 
tients, they do so only when they can prove that the patient 
is taken into the. house, or taken charge of, " for profit," and 
taken charge of " as a lunatic," that is, by one who must 
have known him to be a lunatic. A friend taking charge of 
a lunatic without profit, for friendship's sake alone, would 
not be reached by this portion of the Act, and the Commis- 
sioners could not order the removal, which is only to be 
•effected through the intervention of a magistrate. 

Passing from cases where our difficulty lies in gaining ac- 
cess to the patient, I come to those where opportu- 
ne be aoubt- nities of observation and conversation are afforded, 
but where the insanity of the individual is doubtful 
or difficult to detect, or is denied by himself or certain of his 
friends or relations. The difficulty may lie in the slightness 
of the insanity, or in the ingenuity with which the patient 
baffles our endeavors to detect it. 

If the alleged lunatic has been previously under our care, 
and is known to us, we shall need little information from 
others ; but we are often consulted, as medical men, by the 
friends of patients with whom we are previously unacquainted, 
and of whose sane condition w^e are entirely ignorant. We 

1 Vide p. 410. 



ON THE EXAMINATION OF PATIENTS. 421 

are consulted by friends who wish us either to say that the 
patient is insane or sane, according as they themselves think, 
and they wish, of course, to enlist our assistance and evidence 
to support their own view of the question. Now, do not be 
led away by the ex parte statement which you will receive 
about a doubtful or disputed case of insanity from those who 
first consult you. Do not be induced to be an ex 

*> Information 

parte witness, retained like a barrister on one side of others not 

to foe received. 

or the other. Eeceive all you hear as matter re- without 
quiring proof, and recollect there are two sides to 
all such questions. Before you go into the presence of a 
patient, find out as much as you can concerning him from 
people who differ in the opinion they hold, if it be possible, 
from as many persons of all ranks as you can, relations, ac- 
quaintances, servants, and consider whether their accounts 
agree or not. And if they disagree, and one side represents 
him to be sane, and the other insane, consider which is likely 
to be the better informed, the least prejudiced, the least in- 
terested, and the more reliable. One party, who does not 
wish the patient removed or interfered with, or taken out of 
its hands, will say that he is not violent or dangerous, but 
only a little " excited ;" that all his so-called delusions are 
not delusions, for they are all based on facts. Others will 
justify what he has done, or say that he was provoked to do 
it. " Excited," " excitable," " excitement," are words which 
are bandied about in an extraordinary manner. One person 
is said not to be insane, but only " excited," while " excite- 
ment" in another case is alleged as the chief evidence of in- 
sanity. It is a vague word meaning nothing, and I advise 
you not to employ it in writing certificates, or giving evidence 
concerning insane patients. If friends use it, request them 
to explain what they mean, whether excitement of speech, 
excited acts and gestures, or what? As for delusions not 
being delusions because they are based on something true, we 
know that the greater part of delusions, like dreams, arise 



422 ON THE EXAMINATION OF PATIENTS. 

out of some fact, or combination of facts, and have these as 
their groundwork; but they are none the less delusions. 
And if, on the other hand, friends allege that the patient is 
under delusions, when he holds certain opinions, or asserts 
certain facts, which, though improbable, are possible, you 
will have to consider whether these may be true, even if the 
friends would wish to persuade you that they are all phan- 
toms, or whether a man may not hold extraordinary, or even 
extravagant opinions, without their proceeding from insanity. 
All the information that can be got you will receive and 
weigh, and will then test it by personal conversation and 
examination of the patient. 

I now suppose that you are brought face to face with the 
on visiting a alleged lunatic. If you are shown into a room 
patient. where he is with other people, you may not be able 
to say at a glance which is the individual, and may not be at 
liberty to ask. It is something more than awkward to com- 
mence a conversation with the wrong person, so that I 
strongly advise you to make sure before you enter the room 
that you will have no difficulty in fixing on the right one. 
You can ask such questions concerning the number of people 
there, the appearance of the individual, or the distinguishing 
marks of his dress, as to render any mistake impossible. 
This may seem a piece of trifling advice, but I have known 
the difficulty occur. If you can, get a friend to introduce you, 
and open the conversation, and there can be no better way 
of doing this than by inquiring after the patient's health. 
Frequently you can be introduced by his ordinary medical 
adviser, or you may tell him that you have come as 
his substitute. There will be little difficulty in discovering 
the insanity of the melancholic. Though he thinks he is 
past all human aid, he will freely tell you his woes and 
fancied misfortunes. The gay, exalted, and hilarious para- 
lytic and maniac will disclose his malady readily enough. 
But when you have to deal with the suspicious monomaniac, 



ON THE EXAMINATION OF PATIENTS. 423 

the man of concealed hallucinations and delusions, with pa- 
tients who have been shut up alreadj^ or with people who 
are merely weak-minded, or whose insanity is displayed in 
acts rather than in words and delusions, you may converse 
for a very long time without being able to detect the hidden 
disorder, or to satisfy yourself that what you have heard is 
true, and that what has been done has been done from in- 
sanity, and not from depravity or wanton mischief, subjects of 
There is no better way of commencing the con- conversatlon - 
versation than by inquiring after the patient's health, because 
it is a conversation on a point in which he is concerned. 
You may talk to a man forever on points which do not con- 
cern him, on the weather or the crops, on politics and the 
topics of the day, and he may converse freely, rationally, and 
like an ordinary being, if he has no delusions concerning 
such matters. You must bring round your conversation to 
himself, for this is the point on which he will display his 
insanity. He is the subject of whom all his delusions are 
predicated. You may talk over an enormous range of ground 
and an infinity of topics, you may even talk of matters con- 
cerning which he has delusions, but if you do not connect 
him with them, your labor may be in vain. And now you 
see the advantage of appearing in your own character of 
doctor. Y r ou assume the right of questioning the patient 
about everything which directly or indirectly affects his 
health, such as occupation, residence, mental work or worry, 
habits — in fact, his daily existence. He may assert that you 
are not his medical adviser, that you have no business to 
question him, and that he wants none of your advice ; but 
you will assure him that you have been requested by his 
family or his own medical man to see him, and will tell him 
that they have been alarmed at his symptoms, at what he 
has said, or done, or threatened to do, and this he must ex- 
plain away or deny. And in his justification, explanation 
or denial of insane sayings and doings, he will generally open 



424 ON THE EXAMINATION OF PATIENTS. 

up the real state of his mind. If you gain his confidence, 
and he enters into conversation, it is as a rule not difficult 
to detect the insanity. But he may refuse to talk, and, with- 
out keeping absolute silence as a melancholic or demented 
patient, may yet tell you nothing whatever. Such answers as 
he does give are pertinent and correct, but he will not con- 
verse concerning himself or any one else. When this is the 
case, you cannot sign a certificate, and there is nothing to be 
gained by pressing a patient beyond a certain point ; it is 
better to take your leave and see him again on a subsequent 
day. 

I warned you that in many cases it is time lost to talk on 
indifferent topics which do not concern the patient : for the 
same reason there is nothing to be gained, by going into the 
presence of the patient, ostensibly to talk to some one who is 
in the room with him. You cannot turn from such a person, 
and suddenly commence to question the patient ; and if he, 
upon your entry and assumed business with another, gets up 
and leaves the room, you have no excuse for detaining him. 
Your visit must be to him and to no one else. I mention 
this because it is a plan often proposed by friends, which as 
often fails, and the failure of your first attempt often involves 
the second in greater difficulties. 

You may possibly observe something in the patient's ap- 
pearance, dress, or occupation, which may form a 
appearance topic of conversation and afford a clue to his mental 
peculiarities. It may be so extraordinary as at once 
to indicate insanity, or it may suggest delusions which you 
may by its aid extract. Nor will you forget during the in- 
terview to survey the apartment, supposing it to be the pa- 
tient's own, and notice anything that is bizarre or startling. 

Much has been written concerning the physiognomy of the 
insane. It is supposed that insanity stamps itself in the 
countenance of a man, and is recognizable there. In many 
cases it is, but it is recognizable in some only by those per- 



ON THE EXAMINATION OF PATIENTS. 425 

sons who knew the patient in his sane state. Nevertheless, 
when we approach a patient for the first time, we shall gen- 
erally find that his emotional state shows some peculiarity. 
He is not perfectly easy, unconstrained, and void of all undue 
emotion. Either he is a little too gay, or a little too dull. 
On entering into conversation we may find him in high 
spirits, jocund, hilarious, and boisterous towards a stranger; 
or dull, suspicious, and snappish; or decidedly depressed and 
melancholy. And these various moods may of themselves, 
without further information, aid us in discovering the corre- 
sponding delusions. The gay and hilarious man will have 
exalted ideas concerning himself, his personal strength, 
beauty, and prowess, his wealth, rank, and prospects ; the 
depressed man will have all the delusions of melancholia, 
will think his soul is lost, his fortune and business ruined, 
or his body a prey to all manner of disease : while the irri- 
table and suspicious man will think that there is a conspir- 
acy to ruin him, or that people are accusing him of unnatural 
crimes, that every one looks at him in the streets, and that 
the newspapers refer to him in all they report. From noting 
the general manner and demeanor I have often discovered 
delusions which have been unknown to the friends, and 
hitherto carefully concealed. 

It is always satisfactory to discover delusions. Although 
insanity may and does exist without them, yet 
there can be no doubt of its presence when we dis- aeiusionsta 
cover them. But you must make perfectly sure 
that what you think or are told is a delusion, and one beyond 
all reasonable question. Certain statements admit of no 
doubt. A patient told me that he had the devil in his 
inside, who had converted everything there into cinders, and 
he produced, in support of this, some black powder, which 
he said was his fasces thus converted. But many assertions 
we only know to be delusions from information derived from 
others — information not always forthcoming, and not always 



426 ON THE EXAMINATION OF PATIENTS. 

credible. A very common delusion is that which a man en- 
tertains concerning his wife's infidelity. But if this is all 
you can discover, and you have no informant but the man 
on the one side and the wife on the other, are you necessarily 
to believe her statement that it is a delusion? You will 
consider the man's general state, his mode of asserting the 
fact, and the grounds he gives for his belief, and you may 
very likely, without further testimony, convince yourself 
from his whole story that he is insane. You will in a cer- 
tificate state the delusion, your belief that it is a delusion, 
and your grounds for the belief. Always say that such and 
such a fancy is a delusion, if it is a thing possible to happen 
or to have happened ; or that you believe it to be a delusion, 
and your grounds for such belief. Thus, " The patient tells 
me that he is ruined, which I am assured by his wife, or son, 
or lawyer, is an entire delusion ; " or, " The patient asserts 
that his wife is unfaithful, but he cannot tell me the name 
of any man, or give any grounds whatever for his belief, 
which I look upon as altogether a delusion." 

Friends may have an interest not only in shutting up an 
individual, but in making it appear that statements made 
by one who is undoubtedly insane are all of them delusions. 
Madmen have an unpleasant way of revealing family secrets, 
and it is convenient to call all such revelations delusions. 
Here you must, if possible, derive information from others 
who are not primarily concerned — old servants, medical 
men, acquaintances, and the like. But for them I should 
certainly have been disposed to accept as delusions some of 
the facts that have been told me by patients, and even now 
I am in doubt about some, never having been able to arrive 
at the truth. You must well consider who the person is 
who makes a statement to you concerning a patient and his 
delusions. Is he or she the person who wishes to place the 
patient under restraint ? Has he or she any interest in so 
doing beyond the welfare of the alleged lunatic ? Fathers 



ON THE EXAMINATION OF PATIENTS. 427 

and mothers do not often wish to confine their sons and 
daughters as lunatics, unless they really are such, but it 
sometimes happens that fathers would like to shut up as mad 
an unruly son who is vicious and bad. I receive with the 
greatest caution that which I hear from husbands concerning 
wives, and vice versa. Then, beside the interest which one 
person may have in confining another, we must make all due 
allowance for the possibility of our informant being fright- 
ened, prejudiced, or ignorant. We must also admit of the 
patient's being an ignorant person, or one holding very ex- 
traordinary opinions on certain points, as religion or politics. 
Others who differ with him may look on such ideas as quite 
sufficient to warrant their assertion that the man is mad. 
We must also make due allowance for the class of life of the 
alleged patient, especially if we have to base our opinion 
upon violence of conduct and language. If a gentleman or 
lady of exalted station and refined manners uses blasphemous 
and obscene language and vile epithets, we may reasonably 
question their sanity ; but if one of the plebs calls his wife 
filthy names, and threatens to beat her, it does not follow 
that he is under a delusion as to her fidelity, or that he is 
insanely dangerous or homicidal. All due allowance must 
be made for the rank, station, and previous habits of the in- 
dividual. Counsel may ask us whether we consider swear- 
ing, indecent, or profane language, proof of insanity ? Of 
course it is not, looked at per se ; but when uttered by this 
or that person, it might be as direct evidence of the state of 
mind as anything could be. A lady once told me that she 
knew her husband must be mad when he met her at the 
station in a white hat. Wearing a white hat is not usually 
considered evidence of insanity, but such an act on the part 
of this gentleman — a grave clergyman — convinced his wife 
that something was very much amiss. So, when you hear 
people talk of a patient's having delusions, you must request 
them to state exactly what these are, and it may be that you 



428 ON THE EXAMINATION OF PATIENTS. 

will have to cross-examine them pretty closely before you 
examine the patient. You will then examine him upon 
them, either bringing round the conversation to such points, 
or telling him that you have heard such things alleged of 
him. You need not be supposed to believe them, but you 
can inform him that such things are said of him, and beg for, 
or at any rate hear, his explanation. And if he denies the 
whole that you say you have heard, confront him, if possible, 
with those who have told you. I say, if possible, for friends 
are very reluctant to assist in such matters, and wish that 
the lunatic should not know whence we get our information. 
We are constantly requested not to mention the name of this 
or that informant. Do not be hampered by any promises 
whatever. If a matter is to be mentioned, it must have come 
to us from some one, and patients of the partially insane class 
can see through the shallow subterfuges so often invented by 
friends, and their distrust and dislike are only increased and 
strengthened thereby. 

Still greater will be the difficulties which you will have to 
encounter in signing certificates for patients who 

Examination t t i • -*r i n i , i 

of patients nave no delusions. You may be called on to do 
who have no tills in the case of a man who is said to be " morally 

delusions. •> 

insane," who is altogether altered in character and 
habits, and who in various ways behaves absurdly or out- 
rageously. Everything here will depend on the opportuni- 
ties you may or may not have of recognizing the change in 
the individual. If I can say of my own knowledge that a 
patient is totally altered, it is perhaps the strongest assertion 
that I can make in support of the opinion that he is insane; 
but if I am called in to see for the first time one who is said 
to be thus changed, I cannot compare his present with his 
former state. I can only compare the present with what I 
hear of the past. Now, these patients have generally sense 
enough to behave themselves decently while in the presence 
of a stranger, especially if they know him to be a doctor. 



ON THE EXAMINATION OF PATIENTS. 429 

We do not see their eccentric or insane acts, and they may 
absolutely deny them. They will justify or explain away a 
thousand little sayings and doings which, though they may 
sufficiently illustrate the change which has come over them, 
may, nevertheless, when taken singly, sound trivial, and are 
not enough to constitute insane acts. It is not likely that 
you will be able to sign a certificate in any such case after 
one single interview : probably you will have to visit and 
examine such a patient several times, and a comparison of 
what has passed on the several occasions will greatly aid you 
in coming to a conclusion. If the disorder is acute and 
rapidly advancing, you may discover delusions in a patient 
in whom a week previously there were none : in others de- 
lusions may have existed and have passed away, yet the man 
has not yet recovered, but remains changed, eccentric, rest- 
less, excitable, insane, obviously unfit to take charge of him- 
self or his affairs. In many of these, though w r e can discover 
no delusion, there is obvious intellectual defect. The patient 
rambles from subject to subject, and do what we will we can- 
not keep him to the point. Ask him half a dozen simple 
questions, and you will not get a plain and direct answer to 
one of them. He will display not an incoherence of words, 
such as we find in the babble of delirium or acute mania, but 
an incoherence and inconsequence of thought, which is quite 
unnatural to him and incompatible with the proper conduct 
and occupation of men in general. Then if we question him 
closely as to the extravagance or absurdity of his acts, his 
attempts to justify them are ofttimes ridiculous and childish. 
Before we come into the presence of one of these patients we 
may obtain all the information we can upon the following 
points from as many friends as possible : Is there anything 
which they consider to be the unmistakable origin of the dis- 
order ? Has he had any epileptic, or epileptiform, or apo- 
plectiform attack, or anything at all of the nature of a fit ? 
Has he ever had a blow or fall on the head, or any bodily 



430 ON THE EXAMINATION OF PATIENTS. 

disorder which at the time affected the head ? Has he under- 
gone any serious loss, worry, anxiety, overwork, or loss of 
rest ? If they tell you that he is altered, make them state 
distinctly in what respect he is altered. Are his altered acts 
those of commission or omission ? Does he neglect his busi- 
ness, forget his appointments, forget the dinner hour? Or 
does he buy useless things, or articles at a price beyond his 
means ? Does he keep loose company, ill-treat and abuse 
those nearest to him, profess dislike or indifference to those 
he has hitherto most dearly loved ? Has he become bold, 
noisy and talkative, instead of being shy and reserved ? Has 
he made any extraordinary changes in his personal appear- 
ance, his dress, hair, or beard ? Does he now take more 
drink than he ought, having previously been sober ? Is he 
excessively restless, never settling to anything, but constantly 
coming and going ? From the answers we receive to these 
questions we may, if our informants are credible, satisfy our- 
selves of the patient's insanity before we enter his presence. 
It is probable that such questions will in the main be answered 
truly. We may then ask one more, which is as likely to be 
answered untruly. Has any relative of the patient's ever 
been insane ? In our examination of the individual we shall 
bear in mind all that we have heard, and shall consider the 
mode in which he gives his answers, their coherence, his jus- 
tification or denial of his acts, and the reasons for his treat- 
ment of or estrangement from his family and friends, if such 
exist. And herein, as I have before reminded you, our 
questions must be applicable to the condition, education, and 
station of the individual, be he gentle or simple. We must 
avoid the discussion of abstract right or wrong, and the ques- 
tion of whether such acts as his are right or wrong, 
enormity of We have only to consider whether they were done 
acts, to be ky | 1 * m }) ecai , se ne was insane, and would not have 

regarded. * 7 

been done by him in his sane mind. We are con- 
cerned not with things wrong or right, moral or immoral, 



ON THE EXAMINATION OF PATIENTS. 431 

but with things irrational. As men have held the most ex- 
travagant opinions, so have they committed the most dia- 
bolical crimes, while sane. But the manner and method of 
their deeds and opinions we have to criticize. The argu- 
ments used to uphold them may bring to light an insanity 
not visible in the acts, and may indicate the disorder of the 
mind from whence they sprang. There is a strong love of 
argument and controversy in many such patients, and they 
often defend themselves in an exceedingly ingenious, yet no 
less insane fashion. 

You may have to examine, for the purpose of signing a 
certificate, one who is not and never has been in- 

The exami- 

sane, in the ordinary sense of the word, but whose nation of 
unsoundness of mind is of the nature of weak-mind- 
edness or imbecility, defective rather than insane mind. You 
have here no former condition of healthy mind with which 
to compare the present. You must compare it with an as- 
sumed standard of average humanity, and the question will 
be, at what point will you decide that soundness ends, and 
unsoundness of this description begins ? In conversing with 
such a person you will find no delusions, no loss of memory; 
there will be no definite commencement of the defective 
state, nor any assignable cause. All that you have to guide 
you is of a negative character. It is the absence or nega- 
tion of mind, rather than the positive presence of symptoms 
of insanity. There may be positive vice, vicious habits and 
propensities, fondness for low company, thieving, lying, 
and the like; but your difficulty will be, first, to recognize 
this for yourselves, for such offences will not be committed 
in your presence; and, secondly, to decide whether they pro- 
ceed from depravity and badness, or from imbecility, which 
renders the individual irresponsible. There are many of our 
criminals who, were they higher in society, would be con- 
sidered irresponsible, and placed in asylums; being what 
they are, they fill our jails. But I have already spoken of 



432 ON THE EXAMINATION OF PATIENTS. 

these patients; I here merely wish to make a few suggestions 
for your guidance in dealing with this most difficult class. 
Unless the individual has been under your observation for a 
long time, you will scarcely be able at once to give a decided 
opinion in a doubtful case. The friends will come to you 
strongly biassed. Either they wish to shut up the alleged 
lunatic because he disgraces his family by his vice and in- 
iquities, or they wish to prevent him from squandering his 
property ; or, on the other hand, they wish to make out that 
there is nothing the matter with him, if, perchance, the 
Commissioners in Lunacy consider that he ought to be pro- 
tected by certificates. You will not, therefore, be able to 
receive that which you hear from friends without consider- 
able caution and discrimination. You are brought face to 
face with a youth of this class, and proceed to question him. 
If you tax him with his vices, he either denies them, or, 
admitting them, confesses and acknowledges that they are 
wrong; but probably he can mention many others who do 
the same things. You proceed to test his knowledge ; and 
this, in my opinion, is the only test, especially when vice is 
absent. Is he teachable, capable of receiving instruction and 
profiting by it? The chances are that, being hard to teach, 
dull and disinclined to learn, his education has been neg- 
lected, and he has been placed with tutors to be kept rather 
than taught; or put to learn farming, or sent to sea, or to 
some other calling for which he is equally unfitted. So that 
his ignorance on special subjects may be due to his precep- 
tors rather than to himself. But a gentleman's son ought 
to have learned by the time he is twenty-one to read, write, 
and spell; and if at this age his spelling and letter-writing 
are those of a child of eight, we may reasonably think that 
deficiency may be the cause, if he has had fair opportunities. 
The ignorance and inability to learn may be a good ground 
for making an affidavit for a commission in lunacy that a 
patient is incapable of managing his affairs; but in the matter 



ON THE EXAMINATION OF PATIENTS. 433 

of signing a certificate, I think it also ought to be shown, and 
you ought to be able to say, that in your opinion the individual 
is a proper person to be detained under care and treatment 
as a lunatic, because he is not fit to be at large unless closely 
watched. Many of these people will run away from any place 
in which they are living in a vague and purposeless way. 
They cannot be trusted alone, for they would get into mis- 
chief, and they cannot be allowed to have the control even of 
a small sum of money. Indoors they may destroy furniture 
or their clothes, wantonly set things on fire, or practice hor- 
rible cruelty to children, dogs, or cats. Where we find this 
to be the case, we may reasonably think and say that such a 
one is a proper person to be detained under care and treat- 
ment, if it appears from the mental deficiency that his whole 
condition is that of an imbecile or idiot. 

Far more easy is it to sign certificates for those who, from 
old a«;e or brain disease, are fatuous and demented. 

° t The examina- 

You will here have signs and symptoms of a more ticmofthe 

. . , -, . . „ , , demented. 

certain weight and significance than are to be 
found in the last-mentioned class. You can compare the 
present condition with the past. Whereas a man was once 
vigorous in intellect, clear in conception, and of good memory, 
we now have but the wreck of mind remaining. Chief of all 
we find a failing memory. There is no recollection of what 
happened yesterday or the day before — no recollection of 
your last visit, possibly not even of your name. If a patient 
drifts into dementia from a state of mania or melancholia, we 
may find still some of his old delusions or the traces of them. 
But in many who are demented from paralysis or epilepsy, 
there may be no delusions, but an absence of mind and in- 
tellect — a repetition of the same question, or the same story, 
or the same sentence, with entire forgetfulness of having 
asked such a thing before, and an equal forgetfulness of the 
answer received. You will be asked to sign certificates con- 
cerning such patients to legalize their residence in an asylum 

28 



434 ON THE EXAMINATION OF PATIENTS. 

or family, or to deprive them of their rights by a commission 
of lunacy, and you will, as I have said, have little difficulty 
in coming to a decision. Loss of memory is a morbid state 
far more perceptible and appreciable than the defective in- 
telligence of the weak-minded youths I have last spoken of, 
and such patients demand care and personal attention in a 
way that many of the others do not. Of course, it will be 
for you to consider the extent and the constancy of this 
impairment of memory, and how far it would necessarily 
render a man incapable of managing his affairs. As, on the 
one hand, no person's memory is perfect, as we all at times 
forget a name or date, so, on the other, every man whose 
mind is not completely obliterated, or who is not unconscious, 
can recollect by. the eye, or in some way, something of past 
events, or those persons nearest and dearest to him. There- 
fore, when you meet with imperfect memory the result of 
disease, and no other symptom, you will have to decide 
whether the imperfection is sufficient to render the patient 
unsound of mind in the eye of the law. "Sound mind, 
memory, and understanding," is the phrase lawyers use to 
indicate capacity. Does the patient before you possess all of 
these ? Clearly a man cannot manage his property who can- 
not recollect its nature or amount. If he cannot recollect 
whether he has a wife, or the number of his children, he 
cannot be considered competent to make a will. If he has 
so forgotten places that he does not know whether the house 
he is in is his own or another's, nor the name or situation of 
it, he cannot be said to be dwelling there of his own free 
choice, or to be able to arrange such matters for himself. 
The facts in these cases speak for themselves. An old man 
may dwell in his own house, may sign his name to a piece of 
paper as he is directed, may hand to any one a sum of money 
previously prepared and put into his hand, and so may be 
said to manage his own affairs; but you may find that to-day 
he has totally forgotten every occurrence of yesterday, that 



ON THE EXAMINATION OF PATIENTS. 435 

he knows nothing about his property, thinks people are alive 
who are long since dead, and that all his management con- 
sists in signing everything that is placed before him. Patients 
of this feeble mind are, by reason of their feebleness, con- 
tented and happy. They put up with any treatment, how- 
ever bad. They do not run away, and are said to remain 
voluntarily, wherever they may be. But their volition is as 
feeble as the rest of their minds, and their submission and 
surrender of all independence speak for themselves. And 
they are hopelessly incurable. They have to be taken care 
of for their natural lives, whereas the weak-minded youths 
may, in many instances, be improved. Hopes may be enter- 
tained of them, but of the demented there is no hope. They 
have possessed a mind, but have lost it past recall. There- 
fore certificates may be signed with much less hesitation than 
in the last-mentioned cases. 

Most unquestionably your aid and advice will be asked for 
the purpose of placing under legal restraint the 
inveterate drunkards so often called dipsomaniacs. natloTof^- 
The question of restraining them by special le^isla- callGd " di P s °- 

A t/ x o maniacs." 

tion, and in special inebriate asylums, is attracting 
much attention in the present day; but so far nothing has 
been done in this country, and I have only to speak to 
you of the existing law, which is the law of lunacy. It is 
not easy to advise legislation on the subject. We have at 
present a machinery consisting of Lunacy Acts, asylums, 
and Commissioners in Lunacy, by which any one can be put 
under restraint who is of unsound mind. What further 
addition can be made? Inebriate asylums may be instituted, 
in which people may voluntarily place themselves for the 
cure and -eradication of the habit ; but it is not to be sup- 
posed that legislation will go so far as to sanction the forcible 
incarceration of every person who may be called by his friends 
an habitual drinker. For those who are really of unsound 
mind, the present means are sufficient ; and in the examina- 



436 ON THE EXAMINATION OF PATIENTS. 

tion of one alleged to be a dipsomaniac, you will have to 
ascertain not only that he is a fit person to be taken care of 
and detained, but also that he is of unsound mind. Although 
I cannot hope to give you any very definite or precise rules 
for your guidance in coining to a decision on this most diffi- 
cult point, yet some few hints may be of service. 

I abolish dipsomania from the varieties of moral insanity, 
together with such monomanias as erotomania, pyromania, 
and kleptomania. The unsoundness of mind which exists in 
connection with habitual drinking must be estimated like 
unsoundness in any other individual. Not every drunkard 
is insane, nor can he be confined because he ruins his health 
and property, any more than a confirmed gambler or opium- 
eater. There is an insanity, the marked feature of which is 
a craving for drink, but it is not the condition of a man who, 
after his work is over, goes to the public house and gets drunk, 
whether he does so nightly or occasionally. He may squander 
his money and wreck his constitution, but during his work- 
ing hours he is a sane and intelligent man. It is not the 
condition of a man who periodically drinks himself into de- 
lirium tremens. During the delirium we may, of course, sign 
certificates of insanity, if it is absolutely necessary for his 
protection to do so ; but when he has recovered, he cannot 
be detained because at some future time he will most proba- 
bly drink himself into another attack. In the interval he 
may be a perfectly sane man. 

We shall have no difficulty in signing a certificate when 
unmistakable insanity has been produced by drink, whether 
it present the symptoms of mania, melancholia, or dementia. 
Such will be recognized and dealt with as any other case of 
insanity. 

There are, however, certain persons who seem impelled to 
drink, as others are impelled to murder or suicide. And 
this impulse is so strong, that they are rendered entirely unfit 
to take care of themselves or their affairs. If left to them- 



ON THE EXAMINATION OF PATIENTS. 437 

selves, they would drink continuously till they reached the 
stage of delirium tremens or alcoholic paralysis. Closely ex- 
amining them, we find them to be people who, from congenital 
or acquired weakness of mind, are unable to exercise any self- 
control, and are practically of unsound mind. They may 
have suffered from blows on the head, fits, previous attacks 
of insanity, or they may have by inheritance an insane 
neurosis. They probably desire to place themselves under 
control, and will voluntarily enter an asylum if it be possible. 
Here the drinking is most frequently the result of the insanity, 
which is, however, aggravated by the perpetual alcoholiza- 
tion. 

Except in view of a particular case, one is obliged to speak 
in very general terms of such patients ; but, as I have said 
concerning other doubtful forms of insanity, there is generally 
to be discovered some mental defect or peculiarity other than 
the act or habit of drinking, if we look for it carefully and 
have sufficient opportunity for its discovery. It is for the 
most part quite impossible to sign a certificate upon a single 
examination of one of these, but a longer acquaintance may 
remove our doubts, and enable us to say that he is not of 
sound mind, memory, and understanding. It is of course 
essential that we see him free from the influence of recent 
drink : always inquire into that which an alleged lunatic has 
had to drink since his last sleep: serious consequences might 
ensue were we to sign a certificate for a man who was only 
drunk. 

This drinking insanity may be periodical or permanent. 
In the former case the patient must be liberated, as any other 
who has recovered from his insanity. He may be liberated 
upon trial, and if his recovery is only apparent, he may be 
readmitted. Very frequently it is permanent, and, in fact, 
is only the commencement of a more marked degeneration 
of mind. 



438 ON THE EXAMINATION OF PATIENTS. 

Lastly, in your examination of a patient be careful, above 
everything, that he has fair play. You are about to 
do that which will deprive him of that we all hold 
most dear, and he is in some respects in the position of an 
accused person. You are examining him to satisfy yourself 
of the real state of his mind, not to trip him up and extract 
that which will sound well in a certificate. If he is a per- 
son inferior to you in intellect, you may puzzle him by cross- 
examination, so that he may seem really wrong in his head ; 
but you know that a man in the witness-box may in the same 
way "lose his head," and, without the slightest intention of 
doing wrong, swear black is white. If the case is not urgent, 
and admits of doubt, always see a patient twice before you 
sign. Some vary considerably, especially women, at different 
times, and if possible you should see them at their best and 
at their worst. 

You are not to omit the inspection of a patient's letters 
and writings. Many, who are very shy and reticent when 
brought face to face with a medical man, will in that which 
they write, reveal the delusions and fancies under which 
they are acting. The whole style of a patient's letter, the 
signature and direction, may show the idea predominating 
in the mind ; and defect of intelligence, the imbecile and 
childlike weakness, the failure of mental power, and forget- 
fulness of dementia, may be all displayed in written charac- 
ters. Letters will assist you in finding out concealed ideas, 
or may illustrate points on which you have only been able 
to gain imperfect information from the patient or his friends. 
Once more I must warn you, that you undertake a serious 
responsibility when you sign a certificate of lunacy. You are 
performing an act which deprives another of his liberty and 
rights, and are signing a legal document which you may have 
to defend in a court of law. Never put anything in a certifi- 
cate which you cannot justify in the witness-box. You will 
not be absolved from responsibility because your certificate 



ON THE EXAMINATION OF PATIENTS. 439 

has been received by the Commissioners in Lunacy. A man 
may even be insane, and yet if your certificate be not true, 
and if all the requirements of the law be not carried out, you 
will be held responsible. Let that which you say in it be as 
short as possible, if only it be strong. And do not add to 
the facts which really indicate insanity others which do not 
indicate it at all. Be accurate in the filling up of the whole 
certificate. Scarcely a single certificate is ever sent in from 
a medical man that has not to go back to him for the cor- 
rection of some error or the insertion of something omitted. 
In your statement of facts, see that you state fully what 
you observe and what you mean. Do not write down a series 
of single words, such as "great excitement, delusions, refusal 
of food," but say, " I found the patient looking so and so, 
doing this or that, and he said that," &c. And if what he 
said was not unquestionably a delusion, you must add that 
it is a delusion, as you believe or are informed. And when 
you speak of refusal of food, or excessive drinking, or the 
like, take care that you speak of what you have yourself ob- 
served, or else that you state that such a fact has been com- 
municated to you by others. I often find that the two sets 
of facts are intermingled by medical men. Do not use vague 
terms, as incoherence, excitement, fatuity ; but reduce your 
statements, as far as possible, to the enunciation of concrete 
facts. 

Here, gentlemen, I bring these lectures to a close. They 
are but brief sketches of some among the many topics which 
I might discuss. Of their imperfection no one is so aware 
as myself; nevertheless, they may serve as suggestions for 
further reading and observation ; and I venture to hope that 
you will find, that from them you have derived some hints, 
when at a future time you have to treat insanity, or take 
the necessary steps for placing under legal restraint an in- 
sane patient. 



APPENDIX. 



SYNOPSIS OF THE LAWS OF THE SEVERAL 
STATES OF THE UNION 

RESPECTING THE CONFINEMENT OF THE INSANE. 



Legislation in tins country respecting the confinement of the insane 
in hospitals, asylums, or other places of detention, is of comparatively 
recent origin. It was supposed that they would be cared for and watched 
over by their friends with as much fidelity and tenderness as if their 
disease were of the body rather than of the mind, and accordingly 
they were left to perform this duty in the way and manner which 
seemed most likely to keep the patient from harm and accomplish his 
recovery. Even after the establishment of hospitals supported by the 
state, no express legislation was supposed to be necessary to authorize 
the managers to hold their patients in custody. Various subordinate 
incidents of the measure were prescribed b}' law, while the measure it- 
self — the essential thing — was left to the discretion of the friends. As 
a matter of police, the law always provided for the care of that homeless, 
friendless class, who roamed about endangering the lives and property 
of their fellow-men. Of late years, this general confidence in the mo- 
tives and intentions of men has been somewhat weakened by apprehen- 
sions that the unqualified privilege allowed to the friends of the insane 
to deprive them of their liberty, has been abused. Suspicions have been 
raised that sane persons have been thus imprisoned in order that some 
dishonest relative might be the better able to promote some scheme of 
iniquity. The consequences of this feeling may be seen in much trouble- 
some litigation, and a prevalent distrust and alarm among all who are 
obliged, either by the claims of their profession or of their relation- 
ship, to assume control over the insane. Under this state of feeling, it 
seemed highly necessary, in order to avoid public scandal and furnish 
protection to those who are engaged in the offices of hunianity, that this 



442 APPENDIX. 

privilege of depriving the insane of their liberty should be authorized 
by the legislature, and its conditions so managed as to afford the least 
possible chance for its abuse. For several years this subject engaged 
the attention of the " Association of the Medical Superintendents of 
Hospitals for the Insane, in North America," which finally prepared and 
unanimously adopted the project of a law consisting of such provisions as 
seemed best calculated to accomplish the object in question, and recom- 
mended that they should be incorporated into the law of every state. In 
the states of Pennsj'lvania and Connecticut, this has been already done 
(with some slight modifications) so far as the confinement of the insane 
is concerned. It will serve our present purpose to present entire, in its 
place, the Pennsylvania act. 

In most of the states, the laws respecting the insane have reference, 
in a great degree, to the state hospital, prescribing the conditions on 
which patients can be received. They regulate the confinement of the 
insane in a particular establishment, but are silent respecting this meas- 
ure considered generally. In some, especially the newer states, inter- 
ference with the liberty of the insane is legalized only as a measure of 
police, and in the care of their property they are treated like minors. 

In the following account of the laws of the several states, I have en- 
deavored to give only the essential points, as briefly and comprehen- 
sively as possible. It is possible that very recent legislation may have 
made some changes, but with that exception, it may be received as 
quite correct. The reader will bear in mind, however, that, in many of 
our states, legislation on the subject of insanity is still in a very rudi- 
mentary condition, which will explain some of the apparent deficiencies 
revealed in this sketch. 

MAINE. 

Insane minors may be sent to the hospital by parents or guardians, 
within thirty days after attack. 

In all other cases commitment to the hospital can be made only by 
the municipal authorities of the town or city in which the patient resides. 
These, on application of friends or of a justice, inquire into the mental 
condition of the patient ; and if they think him insane, and that the com- 
fort and safety of himself or others will be promoted by confinement in 
the hospital, they order his committal. He is to be detained till re- 
stored, or discharged by legal process. 

Appeal may be made from the action of municipal authorities, each 
party naming a justice of the peace. These make inquiry and have 
power to reverse* or confirm the decision of the authorities. 



APPENDIX. 443 

Patients in hospital, not committed by the Supreme Judicial Court, 
and not afflicted with homicidal insanity, may be removed by order of 
the municipal authorities, at the end of six months and no sooner, at 
the request of the persons liable for their support. Should these authori- 
ties decline to order a discharge, like application and inquiry may be 
repeated at intervals of six months. 

Persons committed to the hospital under the above provisions may be 
placed under guardianship, on application of the municipal officers to 
the judge of Probate. These certify "that it is for the patient's in- 
terest and to prevent a waste of property," whereupon the judge ap- 
points a guardian without notice to patient. 

Persons on trial for crime, pleading present insanity, are committed 
to hospital, by order of the court, for the purpose of observation. The 
court may take the same step previous to trial, if satisfied that such 
plea will be made. 

Persons acquitted of crime on the ground of insanity are to be sent 
by the court to the hospital, to be there detained till cured, or discharged 
by due process of law. The same course is taken even if the grand jury 
fail to indict, because satisfied of insanity. The discharge of any such 
patient from a hospital may be ordered by an}- judge of the Supreme 
Judicial Court. Also by two justices of the peace, respectively named 
by friends of the patient and trustees of the hospital — " on satisfactory 
proof being given that if enlarged he would not be dangerous to the 
peace and safety of the community." Still further, the discharge may 
be ordered by the judge of Probate upon sufficient recognizance for 
safe-keeping. 

Any convict in the penitentiary, supposed to be insane, is to be ex- 
amined by a committee of two or more ptrysicians appointed by the 
governor. If found insane he is to be placed in the hospital. 



NEW HAMPSHIRE. 

" The parents, guardians, or friends, of any insane person, may cause 
him to be sent to the asylum." The certificate of one physician to the 
fact of insanity is required by the rules of the asylum. 

A judge of Probate may order the confinement of a lunatic who is 
dangerous to be at large ; notice being first given to the selectmen of 
the town to which said lunatic belongs, or to his guardian, " or to any 
other person, as the judge may order." 

Pauper lunatics may be placed in the asylum by the overseers of the 



444 APPENDIX. 

poor of the towns to which they belong. If the overseers fail to do so, 
the Court of Common Pleas may order the committal. 

A lunatic confined in any jail may be sent to the asylum by the Court 
of Common Pleas. 

Lunatics confined in the state's prison may be placed in the asylum 
by order of the governor and council. 

Patients committed by judges or courts are to be detained till dis- 
charged by "due process of law," or, "till the insanity is removed." 

" Any person committed to the asylum, may be discharged by any 
three of the trustees, or by any justice of the Superior Court, whenever 
the cause of the commitment ceases, or a further residence at the 
asylum is, in their opinion, not necessary." 

Application for guardianship of an alleged lunatic is to be made to 
the judge of Probate, who directs the selectmen of the town to which 
the said person belongs to make inquisition and examination into the 
case. If after personal examination they report him to be insane, the 
judge appoints a guardian ; first, however, serving a notice upon the 
patient and citing him to appear and show cause why the application 
should not be granted. 

VERMONT. 

Private patients are admitted to the insane asylum upon application 
of relatives or friends, with a certificate of insanity from a respectable 
physician. 

When it is desired to place an insane person under guardianship, 
application is made to the Probate Court, by relatives, friends, or over- 
seers of poor. This court thereupon commissions two justices of the 
peace to inquire into the facts. These personally examine the patient, 
giving him notice in advance. Upon their report the court appoints or 
refuses to appoint. 

When a person tried for crime is acquitted on the ground of insanity, 
the jury shall state the fact in their verdict. If in the opinion of the 
court it would be dangerous to the peace and safety of the community 
to allow the person to go at large, the court shall order his confinement 
in the hospital or elsewhere. If the offence committed have been 
murder or manslaughter, he may be placed either in the hospital or the 
state prison at discretion of the court ; if some other crime, in the 
hospital, or the county jail, or other suitable place. The expense shall 
be borne by the party, if he have property ; otherwise by the state. 

If in the case of any person held in prison on charge of committing 



APPENDIX. 445 

some crime or misdemeanor, the grand jury fail to indict, through a 
belief in his insanity, they shall certify this fact to the court. If in the 
judgment of the court his enlargement would be dangerous, confine- 
ment may be ordered, in jail, hospital, or other place, at discretion of 
the court ; and the expenses met as in the preceding case. 

When a convict confined in state prison for life, or for a specified 
term, shall have exhibited indubitable symptoms of insanity for at least 
thirty days, the directors of the prison may, at their discretion, cause 
his removal to the hospital, there to remain until recovery or expiration 
of sentence. If recovery oqcur before expiration of term, he shall be 
returned to the prison, and there serve out the remainder of his time. 
Any prisoner recovered from insanity, but not yet returned to prison 
from the hospital, who may abscond from the hospital or from his keeper, 
shall suffer the penalties attached to escaping from state prison. 

Any insane convict not recovered at the end of his sentence, ma} 7 be 
placed in, or continued in, the state hospital, at the expense of the 
state or other parties who may be found responsible. 

MASSACHUSETTS. 

The certificates of two physicians, given within one week after inquiry 
and personal interview, are necessary to secure the admission of a 
patient into any hospital for the insane. One of these is to be, if pos- 
sible, the patient's family physician. If the hospital be a state institu- 
tion, notice of the application must be given to the mayor or selectmen 
of the patient's place of residence. In either case, full written state- 
ments of the history and character of the patient's disease must be sent 
to the hospital, and there preserved. 

Any judge of Supreme, Judicial, Superior, Probate, Boston Police — 
and in certain cases Municipal — Courts, may commit to a state lunatic 
hospital any insane person whom he may deem fit. Certificates of two 
physicians are still essential. 

The judge may appoint place of hearing complaint at his discretion; 
and may either require or dispense with the presence of the alleged 
lunatic. He may also in his discretion summon a jury of six to hear 
and determine as to the insanity of the party complained of. 

Insane paupers ma} 7 be committed by the overseers of the poor. 

Patients in insane hospitals may be discharged by the trustees of 
hospital, by judges of Probate, Supreme, Judicial, and Superior Courts. 

When a person accused of crime is acquitted by reason of insanity, 
or fails to be indicted for the same cause, the court may order his con- 
finement in one of the state lunatic hospitals. 



446 APPENDIX. 

Convicts in state prison alleged to be insane are examined by a 
commission, consisting of the prison physician and four superinten- 
dents of Massachusetts insane hospitals. This reports to a judge of the 
Superior Court, who if satisfied of the existence of insanity, orders 
removal of convict to a state hospital, there to be treated until sufficiently 
restored to be properly returned to prison. Persons confined in other 
places may be placed in hospital upon representation of facts by the 
attending physician to a judge of Superior or Probate Court. 

Upon petition under oath, setting forth belief that a certain person 
is unjustly confined as a lunatic, made to a judge of the Supreme Judi- 
cial Court, the judge may at discretion appoint a commission of three 
to make inquiry. This body shall be sworn, and shall give notice to 
petitioner and to the authorities of the hospital, shall summon and swear 
witnesses, hear evidence, and make personal examination. No notice 
is to be served on patient, nor is he to have counsel, or be present at 
inquiry. He is not to be examined by petitioner or counsel, unless by 
permission of his ptrysician, or by special order of the judge. The 
commission are to visit the patient at the hospital, and not remove him. 
Report of commission being made, the judge takes such action as he 
deems proper. 

Guardians are appointed by the Probate Court on the petition of 
relatives, friends, or town authorities. The court must give the alleged 
insane person fourteen days' notice of the time and place fixed upon for 
the hearing. If after a full hearing the court is satisfied of the person's 
incapacity, it appoints a guardian of his person and estate. 



RHODE ISLAND. 

Insane persons may be placed in the hospital by their legal guardians 
if any ; otherwise by their relatives or friends ; or, if paupers, by the 
authorities of their respective towns or cities. A certificate of insanity 
signed by one physician is always essential. 

Any justice of the peace, upon complaint of any respectable person 
that another is furiously mad and dangerous to be at large, may commit 
the alleged lunatic to the hospital. 

Upon written statement, made by any respectable person, to any 
judge of the Supreme Court, that another is insane, and that his own 
or others' welfare requires his restraint, the judge shall at once appoint 
a commission of three persons, who shall take evidence, receive the 
statements of the alleged lunatic or his counsel, and make full inquiiy 
into the facts. Reasonable notice must be given to the party complained 



APPENDIX. 447 

of, who may be arrested if he fail to appear ; and who, at the discretion 
of the judge, may be confined while the inquisition is pending. If this 
commission report that confinement is advisable, the judge shall make 
an order to that effect. 

Upon written statement, similarly made, that a certain person is un- 
justly confined as insane, a commission is appointed as above, to hear 
evidence and examine the patient. If they report the patient not insane, 
the judge shall order his release. 

If a person charged with crime be acquitted on the ground of insanity, 
the jury shall state that fact. If the judge consider the accused unsafe 
to be at large, he shall thus certify to the governor, who is thereby 
authorized to provide for the maintenance of the prisoner and cause him 
"to be removed to any insane hospital, either within or without this 
state, during the continuance of such insanity." 

Removal of patients from hospital may be effected, generally, by the 
parties who placed them there. 

Application for placing under guardianship a person alleged to be in- 
sane may be made to the Court of Probate, by relatives, friends, or 
municipal authorities. Notice is issued to the patient of the hearing. 
If, however, representation is made to the court by the plrysician in 
charge of the patient, that knowledge of, or presence at, the hearing, 
would be seriously injurious to his health, these are dispensed with, 
and the order of guardianship given or refused at the discretion of the 
court. 

CONNECTICUT. 

Patients are placed in the insane hospital by "legal guardians, or 
relatives, or friends in case of no guardian ;".but in no case without the 
sworn certificate of at least one physician, given within one week after 
personal examination. Such patients are removable by the parties com- 
mitting them to the asylum. 

Any justice of the peace, complaint being made, may investigate the 
state of an alleged lunatic, and if he find him dangerous to himself or 
others, or requiring hospital care and treatment — he being at large — he 
shall order him to be confined in some suitable hospital or other suitable 
place of detention. This, however, shall be done only upon a medical 
certificate as before described. 

On application of an}' respectable person, an} T judge of the Superior 
Court shall appoint a commission of three or four — at least one to be a 
plrysician, and one a lawyer, or judge, or justice — whose duty it shall be 
to inquire into the alleged insanity of the person complained of. They 



448 APPENDIX. 

shall hear such evidence as may be offered, and the statement of the 
party complained of, and his counsel. Upon these they shall report as 
to the fact of insanity and the advisability of confinement. Due notice 
must be given to the alleged lunatic of the proceedings ordered by the 
judge. The judge is authorized to place the party in confinement while 
the case is pending. 

Upon complaint of any respectable person that another is unjustly 
confined as insane, the judge of the Superior Court may, at his discre- 
tion, appoint a commission, as before described, to investigate the facts. 
These shall hear evidence, and shall have one or more personal inter- 
views with the patient, " so arranged, if possible, that such person shall 
not know or suspect the object or purpose of such interview." If this 
commission shall report the patient sane, the judge shall order his dis- 
charge. 

A like commission shall be appointed with like duties whenever the 
officers or managers of an asylum, hospital, or other place of detention, 
may request it. 

Commissions at the request of outside parties shall not be appointed 
during the first six months of detention, when this is by order of a judge 
of a Superior Court. Nor shall such inquiry be repeated, in any one 
case, at a less interval than six months. 

Upon receiving satisfactory evidence that a person is insane, and suf- 
fering for want of proper care or treatment, a judge of the Superior 
Court ma}^ order him to be placed in a hospital, or other suitable place, 
at the expense of those who are legally responsible. 

Patients in hospital under any of the above provisions may be dis- 
charged by the hospital authorities in accordance with their rules. 

Persons acquitted of crime on account of insanity, shall be sent to 
jail by the court. By entering suitable recognizance, any other persons 
may remove them and confine them as the court may direct or approve. 

Application for discharge of such persons may be made to the County 
Court, which may dispose of them as it deems proper. 

Applications for guardianship of lunatics are made to the Probate 
Court by some relative, or by selectmen of the town to which the party 
belongs. The court, if satisfied, appoints a " conservator." The 
patient is summoned to appear, by a copy of the writ being left at his 
usual place of abode. No legal provision is made for the restraint of 
his person ; but this would be permitted. 



APPENDIX. 449 



NEW YORK. 



Persons complained of as furiously mad are confined by order of two 
justices of the peace, with the provision that within ten days they shall 
be placed in a hospital for the insane. 

If any person becoming furiously mad has property of his own, or 
has relatives or guardians liable for his support, it shall be their duty 
to send him to a hospital. Failing this, the overseers of the poor make 
complaint as above, and cause his removal to a hospital, recovering 
expenses by suit. 

No alleged lunatic shall by any process be confined without the sworn 
certificate of two reputable physicians ; a brief report of the evidence 
to be filed in the office of the county clerk. 

Any alleged lunatics adjudged insane and ordered to be confined by 
justices of peace as above, have, or their friends for them, power of 
appeal to a county judge. He shall sta} r removal of any such lunatic, 
and forthwith call a jury to investigate the case. The jury, aided by 
the testimony of two reputable physicians, finding him sane, the judge 
shall at once discharge the prisoner ; otherwise he confirms the order 
for immediate removal to an asylum. The parties making complaint 
against an alleged lunatic, may, if the justices refuse to order confine- 
ment, likewise appeal to a county judge. He may summarily determine, 
or call a jury, as he thinks fit. 

The discharge of patients from the state hospital is wholly in the 
hands of its managers — excepting persons confined on criminal charges 
— who, however, are to be guided by the certificate of the superinten- 
dent, as to recovery, safety, incurability, or insusceptibility to further 
benefit from treatment. Patients of the criminal class may be dis- 
charged by order of a justice of the Supreme Court, if on investigation 
it seem safe, legal, and right so to do. 

When a person is acquitted, or escapes indictment by reason of in- 
sanit}', the jury shall certify that fact to the court, which shall inquire 
into his present condition, and if he be found insane shall order him to 
be sent to the asylum. 

If any person in confinement under indictment, or under sentence 
of imprisonment, or under a criminal charge, or held for want of bail, 
or as witness, or to keep the peace, &c, shall appear to be insane, the 
county judge shall investigate his state, calling upon two respectable 
physicians and other witnesses, and, if he deem it best, call a jury to 
decide as to his sanit}* . If satisfied of his insanity, the judge may order 
his removal to the asylum, to be there confined till recovered. 

When the physician of either state prison shall certif}' that any con- 

29 



450 APPENDIX. 

vict in his charge is insane, the inspector or board of inspectors shall 
examine said convict, and if satisfied of his insanity shall order his 
removal to the asylum for insane convicts. If he continue insane after 
term of sentence expires, he may be sent to his county almshouse, or 
given into the custody of his friends, upon proper sureties; or, upon 
medical and other evidence, the county judge may order his continued 
confinement, in said asjdum, beyond term of sentence. If a convict 
recover sanity before expiration of sentence, he is removed to the 
Auburn State Prison for the remainder of his time. 

Applications for the appointment of "committees" (guardians) for 
alleged lunatics, are made to the Supreme Court, the County Courts, the 
Court of Common Pleas in New York County, and the Superior Court of 
the City of Buffalo. Petition, with reasons, is addressed to the proper 
court, which, if it see fit, appoints a commission to examine and inquire 
into the case. The lunatic is entitled to due notice — though dangerous 
madness, or peculiar circumstances, may excuse this notice. The com- 
missioners summon a juiy and witnesses. The alleged lunatic is entitled 
to be present, and may have counsel. He may be inspected and exam- 
ined. If the jury find him insane, and the commission so report, the 
court appoints the "committee" at its discretion, in the interest of the 
lunatic. Often there is one committee for estate and another for person ; 
the latter generally some of the nearest of kin. The Supreme Court 
has the general care and control of the person and property of the in- 
sane. Upon recovery of an insane person, application is made to this 
court for removal of committee and restraint. 



NEW JERSEY. 

Friends may place a patient in the state asjdum, by signing a written 
request, and presenting a certificate of insanity signed by one physician. 

Paupers may be committed by any judge of the County Court, on 
application of the overseers of the poor, in case said judge shall be satis- 
fied by respectable medical testimony that the pauper is curably insane. 

Persons insane and indigent, but not paupers, may be committed to 
the asylum by two judges of the County Court, if satisfied by medical 
testimony that the cases are curable. 

Persons who have escaped indictment, or been acquitted of a criminal 
charge, on the ground of insanity, shall be committed to the asylum, if 
the court be satisfied that the insanity still continues. 

If any person shall become insane while in confinement under indict- 



APPENDIX. 451 

nient, or on civil process, the court, after ascertaining the facts by care- 
ful inquiry, may order removal to asylum. 

Application for the appointment of a guardian ma}^ be made to the 
Court of Chancery, which thereupon appoints a commission of inquiry. 
If this commission find the party incapable, their finding is returned to 
the Orphans' Court of the proper county, which appoints a guardian. 



PENNSYLVANIA. 

The following is the text of the act of April 20th, 1869, now in force 
in Pennsylvania : 

"Section 1. Be it enacted by the Senate and House of Representatives 
of the 'Commonwealth of Pennsylvania in General Assembly met, and it 
is hereby enacted by the authority of the same, That insane persons may 
be placed in a hospital for the insane b} T their legal guardians, or by 
their relatives or friends in case the} T have no guardians, but never with- 
out the certificate of two or more reputable physicians, after a personal 
examination, made within one week of the date thereof, and this certifi- 
cate to be duly acknowledged and sworn to or affirmed before some 
magistrate or judicial officer, who shall certify to the genuineness of 
the signature and to the respectability of the signers. 

"Section 2. That it shall be unlawful, and be deemed a misdemeanor 
in law, punishable by a fine of not exceeding one hundred dollars, for 
any superintendent, officer, physician, or other employee of &ny insane 
asylum to intercept, delay, or interfere with, in any manner whatsoever, 
the transmission of an} 7 letter or other written communication addressed 
by an inmate of any insane asylum to his or her counsel, residing in the 
county in which the home of the patient is, or in the cit} T or county in 
which the asylum is located. 

" Section 3. On a written statement, properly sworn to or affirmed, 
being addressed by some respectable person to any law judge, that a 
certain person then confined in a hospital for the insane is not insane, 
and is thus unjustly deprived of his liberty, the judge shall issue a writ 
of habeas corpus, commanding that the said alleged lunatic be brought 
before him for a public hearing, where the question of his or her alleged 
lunacy may be determined, and where the onus of proving the said 
alleged lunatic to be insane shall rest upon such persons as are restrain- 
ing him or her of his or her liberty. 

"Section 4. Whenever any person is acquitted on a criminal suit on 
the ground of insanity, the jury shall declare this fact in their verdict, 
and the court shall order the prisoner to be committed to some place of 
confinement for safe keeping or treatment, there to be retained until he 
may be discharged in the manner provided in the next section. 

" Section 5. If, after a confinement of three months' duration, any 
law judge shall be satisfied by the evidence presented to him that the 
prisoner has recovered, and that the paroxysm of insanity in which the 
criminal act was committed was the first and only one he had ever ex- 



452 APPENDIX. 



perienced, he may order his unconditional discharge ; if, however, it 
shall appear that such paroxysm of insanity was preceded by at least 
one other, then the court may, in its discretion, appoint a guardian of 
his person, and to him commit the care of the prisoner, said guardian 
giving bonds for any damage his ward may commit : Provided always, 
That in case of homicide or attempted homicide the prisoner shall not 
be discharged unless in the unanimous opinion of the superintendent 
and the managers of the hospital, and the court before which he or she 
was tried, he or she has recovered and is safe to be at large. 

" Section 6. Insane persons may be placed in a hospital by order of 
any court or law judge, after the following course of proceedings, namely : 
On statement, in writing, of any respectable person, that a certain per- 
son is insane, and that the welfare of himself or of others requires his 
restraint, it shall be the duty of the judge to appoint, immediately, a 
commission, who shall inquire into and report upon the facts of the case. 
This commission shall be composed of three persons, one of whom at 
least shall be a physician and another a lawyer ; in their inquisition they 
shall hear such evidence as may be offered touching the merits of the 
case, as well as the statements of the party complained of or of his coun- 
sel; if, in their opinion, it is a suitable case for confinement, the judge 
shall issue his warrant for such disposition of the insane person as will 
secure the object of the measure. 

" Section 7. On statement, in writing, to airy law judge, by some friend 
of the party, that a certain person placed in a hospital under the fifth 
section is losing his bodily health, and that consequently his welfare 
would be promoted by his discharge, or that his mental disorder has so 
far changed its character as to render his further confinement unneces- 
sary, the judge shall make suitable inquisition into the merits of the 
case, and, according to its result, ma}^ or maj T not order the discharge 
of the person. 

" Section 8. Persons placed in any hospital for the insane may be 
removed therefrom by parties who have become responsible for the pay- 
ment of their expenses : Provided, that such obligation was the result 
of their own free act and accord, and not of the operation of law, and 
that its terms require the removal of the patient in order to avoid further 
responsibility. 

" Section 9. If it shall be made to appear to any law judge that a 
certain insane person is manifestly suffering from the want of proper 
care or treatment, he shall order such person to be placed in some hos- 
pital for the insane, at the expense of those who are legally bound to 
maintain such insane person ; but no such order shall be made without 
due notice of the application therefor shall have been served upon the 
persons to be affected thereby and hearing had thereon. 

" Section 10. If the superintendent or officers of any hospital for the 
insane shall receive any person into the hospital after full compliance 
with the provisions of this act, no responsibility shall be incurred by 
them for any detention in the hospital. 

"Section 11. That nothing in this act shall be construed so as to 
deprive any alleged lunatic or habitual drunkard of the benefit of the 
writ of habeas corpus or trial by jury, or any other remedy guaranteed 



APPENDIX. 453 

to alleged lunatics or habitual drunkards by any existing laws or statutes 
of the Commonwealth of Pennsylvania." 

Any court of Common Pleas may issue a commission of one or more 
persons, in the nature of a commission de lunatico inquirendo, which 
shall summon a jury of not less than six nor more than twelve men, to 
try a question of lunacy. Application for such commission is to be 
made by a relative, by blood or marriage ; or One interested in the estate. 
The inquisition may be traversed b} T any one who is aggrieved. Upon 
a finding of insanity, the court appoints a committee of person and 
estate. 

DELAWARE. 

The trustees of the poor in the several counties are required, on 
recommendation of the chancellor and the resident associate judge of 
either county, to place in some hospital for the insane the insane poor 
of their county. The Levy Court has power to remove an insane person 
from jail or prison to an almshouse. The Court of Chancer}', after 
ascertaining insanity by means of a jury, appoints "trustees" for the 
person and property of lunatics not indigent. 



MARYLAND. 

On application being made, the Circuit Court of the count}', or the 
Criminal Court of Baltimore, will cause a jury of twelve men to investi- 
gate the mental condition of an alleged lunatic. If he be found to be 
insane, and also a pauper, the court at discretion send him to alms- 
house, hospital, or other place of confinement. 

If an alleged lunatic be complained of as dangerous, or for breach of 
peace, a similar course is pursued, though he be not a pauper. 

A person tried for crime, if acquitted on the ground of insanity at 
time of crime, and found to be insane at time of trial, shall be sent by 
the court to the almshouse, hospital, or other confinement at its discre- 
tion, there to be held till " he shall have recovered his reason, and be 
discharged by due course of law." The same course is to be pursued 
with a person charged with improper conduct, or any crime, but not 
indicted; jury, as before, inquiring whether he was, and still is, insane. 

If any of the above persons possess property, the court appoints a 
trustee. 

The general care and custod}- of persons non compos mentis lies with 



454 APPENDIX. 

the Court of Chancery, both as to person and estate. The trustee ap- 
pointed by this court may commit the patient to a hospital only at the 
direction of the court. 



DISTRICT OF COLUMBIA. 

Private patients may be committed to the Government Hospital for 
the Insane upon the certificate of two respectable plrysicians of the 
District. 

Whenever any judge of the Circuit or Criminal Court, or justice of 
the peace, reports to the Secretary of the Interior that two respectable 
physicians have certified to him, under oath, that they know the party 
alleged to be insane, and believe him a fit subject for hospital treatment, 
the secretary shall make an order for his admission to the hospital. 

Persons charged with crime and found insane, and also convicts 
becoming insane in the penitentiary, are sent to the hospital by order 
of the secretary. 



OHIO. 

Complaint of lunacy is made under oath to any judge of Probate. 
He summons the accused, together with witnesses, including one phy- 
sician. Satisfied of insanity, he may order commitment to the insane 
asylum or to other place of confinement. He has power also to appoint 
guardians of person and estate. 

All persons confined as insane are entitled to the benefit of the writ 
of habeas corpus. This may be indefinitely repeated, upon alleged 
recovery. 

Any person accused of crime or* misdemeanor, alleged insane at time 
of offence, is brought before an examining court. If found insane, he 
may be committed to confinement as a lunatic. 

Persons acquitted on ground of insanity ma}^ be ordered to be con- 
fined, if the judge deem them unsafe to be at large. Persons becoming 
insane while in confinement, after sentence of death or imprisonment, 
may be pardoned, or have sentence commuted or suspended, at discre- 
tion of the governor. Persons otherwise confined may be transferred 
to hospital or almshouse by a judge of Probate, if he be satisfied of 
their insanity. 



APPENDIX. 455 



INDIANA. 



Complaint of lunacy may be made to any justice of the peace. He 
summons a jury of six, sworn to be unprejudiced, unrelated, and unin- 
terested. If they find a verdict of sanity, or not dangerous to be at 
large, costs fall on the complainant. Otherwise, the judge appoints a 
temporary custodian, and within ten days reports the case to the Court 
of Common Pleas. This re-tries the case with a jury of twelve men. 
If he be found insane, the appointment of a custodian is confirmed ; 
and if there be property, a guardian is appointed. If on the original 
examination the justice and jury of six find him not insane or danger- 
ous, complainant may appeal to the Court of Common Pleas. If he fail 
to obtain a verdict of insanity, complainant forfeits one hundred 
dollars. 

Application for guardianship is made to the Probate Court. A jury 
is summoned to investigate the facts. The judge may dispense with 
the personal appearance of the party, if satisfied it would be detrimental 
to his health. If found to be insane, a guardian is appointed by the 
judge. 

ILLINOIS. 

No person can be held in confinement as insane, unless by order of a 
court and in accordance with the verdict of a jury. 

Commitment of a patient to confinement as a lunatic is effected as 
follows : An}' respectable person makes a written statement to any cir- 
cuit or count}' judge that A. B. is insane and requires confinement. 
With this application is inclosed a certificate of insanity signed by two 
physicians. Upon receiving these, the judge causes the party to appear 
before him and convenes a jury to try the question of insanity. If a 
verdict of insanity be given, the judge makes an order for commitment 
to the state hospital. If the lunatic have property, a " committee " is 
appointed by the court. 



MICHIGAN. 

The indigent insane are admitted to the hospital by order of a Pro- 
bate judge. The facts of insanity and indigence are testified to by two 
respectable physicians, and other witnesses called by the judge. If satis- 
fied of the truth of the allegations, the judge orders patient to be 



456 APPENDIX. 

supported at the hospital by the county for two years, unless sooner 
restored. 

No insane person shall be confined in the same room with a criminal ; 
nor in any jail longer than ten daj^s. 

Upon application for guardianship, made by relatives or friends of 
any insane person, to the Probate Court, the judge shall give fourteen 
days' notice to the party concerned, naming time and place of hearing. 
Upon full examination and hearing, the judge appoints, or declines to 
appoint, a guardian of person and estate. 

A person in confinement, waiting trial, or in various other circum- 
stances, may, after careful medical examination by order of certain 
courts, be transferred from jail to the insane hospital, to remain till 
cured. If a grand jury decline to indict an offender, on account of 
insanuy, the judge may discharge, or order continuance in prison. 

If a jury shall acquit on the ground of insanity, the court will dis- 
charge, or commit to prison, according as the prisoner's enlargement 
seems safe or dangerous. 

Convicts becoming insane, may, by order of the Circuit Court of the 
county where imprisoned, be given into the custody of the superintend- 
ents of the poor in said county. 



WISCONSIN. 

Patients are admitted to the insane hospital upon the certificate of 
insanity of two skilful physicians, resident in the same county as 
patient. The fact of medical examination and genuineness of signa- 
tures is certified by the local municipal authorities. 

Alleged improper confinement in hospital is to be inquired into by 
the trustees of that institution, aided by two or more "skilful and ex- 
perienced physicians" whom they shall elect for the purpose. All 
patients are entitled to the benefits of habeas corpus. This writ may 
be repeated in the same case, if it be alleged that recovery has occurred 
since the first issue. 

When a jury acquits on the ground of insanity, they state that 
ground. The judge, at his discretion, discharges, or, if safety require, 
commits to prison, or delivers to friends, on proper surety for safe- 
keeping. He may also place such criminals, or those becoming insane 
after conviction, in the insane hospital, but must remove them on cer- 
tificate from the superintendent that their presence is detrimental to the 
safety and welfare of other patients. 

Convicts in state prison, becoming insane, are examined by three 



APPENDIX. 457 

physicians appointed by the governor. On their affidavit of the exist- 
ence of lunacy, he may cause removal to some safe and convenient 
insane hospital, for treatment, till cured or till expiration of sentence. 

Guardianship is obtained upon a sworn statement made to any judge 
of the County Court. Upon receiving such petition and statement, the 
judge gives the person concerned fourteen days' notice. The partj 7 is 
to personally appear at the hearing, " if able to attend." If satisfied 
of the propriety of the step, the judge appoints a guardian of person 
and estate. 

MINNESOTA. 

Private patients are admitted to the hospital for the insane upon 
request of relatives, and approbation of the superintendent, without 
medical certificate. 

Complaint against a person as insane, is made before a judge of Pro- 
bate or a county commissioner. A commissioner, or justice of the 
peace, of the same county, or anj r relative by blood or marriage, may 
apply to a judge of Probate for guardianship. This judge names time 
and place for hearing, cites accused to appear; gives him and some 
near relative not applying for guardianship, six days' notice of proceed- 
ings. The judge summons a jury of six ; counsel is allowed, and wit- 
nesses, including one physician, called. If the jury find the party to be 
insane, the judge appoints from one to three guardians. Guardianship 
may be terminated by the same judge without a jury. 

Upon complaint of insanity being proved, the judge has power to 
commit to hospital only when destitution is also proved. 

When a jury state that they acquit an accused on the ground of 
insanity, the court shall discharge, if it deem him safe to be at large. 
Otherwise shall order confinement in prison ; or deliver, under security 
for safe-keeping, to friends. 



IOWA. 

In this state the care of the insane is wholly vested in a standing 
commission of three, appointed in each county by the Circuit Court. 
This commission consists of one lawyer, one physician, and the clerk 
of the Circuit and District Courts for that county. It is the duty of this 
commission to receive complaints, and investigate all cases of alleged 
insanity. No person can be admitted to the hospital for the insane, ex- 
cept by their order. On receiving a complaint that any resident of the 



458 APPENDIX. 

county is insane, they instruct some respectable physician to examine 
the party, and report to them immediately. This examining physician 
may be the medical member of the commission, or the family physician, 
or any other. In their discretion they may forthwith act upon his re- 
port, and send or decline to send the patient to the hospital ; or they 
may have the patient before them for further examination before final 
decision. The jurisdiction of this commission is complete in its county, 
extending alike to private and pauper patients, rich and poor, quiet and 
dangerous. 

Complaints of illegal confinement in the insane hospital may, however, 
be made to, and investigated by a court. 

Probate judges have power at their discretion, on proper application 
being made, to appoint guardians, when satisfied of the necessity. The 
wife of an insane man shall, if competent, be one of his guardians. 



KANSAS. 

When any person shall become furionsl}^ mad, or so as to endanger 
his person or the persons or propert}' of others, it is the duty of his 
guardian, relatives, " or other person under whose care he may be, and 
who is bound for his support," to restrain and confine him temporarily. 
Failing friends, the same duty devolves on any judge of a court of 
record or any two justices of peace who may be cognizant of the facts. 
Complaint must be at once made by friends or others to the Probate 
judge of the county. If he believe the complaint to be well founded, 
he summons a jury to make inquisition. He may set aside the verdict 
of one jury, but cannot disregard two concurrent verdicts. 

Upon verdict of insanity being rendered, the judge appoints a guar- 
dian of person and estate. 

NEVADA. 

Upon sworn complaint, representing any person as dangerous to be 
at large, any district judge may summon the party before him. He 
also calls two or more witnesses who have been with and near the party 
since he became insane, to testify to words, conduct, and manners. 
Two plrysicians also are summoned to be present, hearing witnesses and 
examining accused. If these physicians certify to recent and curable 
insanity, or to suicidal, homicidal, or otherwise dangerous madness, 
and if the judge be satisfied of the truth of the allegation of insanity as 



APPENDIX. 459 

specified, he shall direct the person to be delivered into the charge of 
the Secretary of State. He shall also determine as to whether patient, 
friends or state are responsible for expenses. Shall appoint a guardian 
if the patient have property. The Secretary of State shall take meas- 
ures to place his insane wards in the insane asylum, at Stockton, Ca. 



CALIFORNIA. 

Upon a complaint under oath, made to any count}' judge, that a cer- 
tain person is dangerous to be at large, or is " suffering from mental 
derangement," the judge summons the accused to appear before him. 
He at the same time and place secures the attendance of two respect- 
able physicians. If satisfied from examination and evidence that the 
party is unsafe to be at large, he orders his commitment to the insane 
asylum. 

Guardians are appointed by the Probate courts. Upon receiving a 
sworn petition, representing insanity and incapacity, the Probate judge 
gives the party five days' notice of the fact. " If able to attend," the 
person is brought before the judge. The truth of the petition being 
established to his satisfaction, he appoints a guardian. 

The courts have power to commit to the insane asylum any person 
charged with an offence punishable with death or imprisonment who 
shall have been found to be insane at time of offence, and who con- 
tinues so. 

VIRGINIA. 

Upon suspicion of insanity, any justice may summon the party to 
appear before him. Calling to his aid two other justices, he examines, 
and hears evidence from physicians and others. If satisfactory proof 
of insanity is adduced, the patient may, at discretion of the justice, be 
committed to the state asylum for the insane, or delivered to the friends, 
under security for safe-keeping and proper care, till cause of confine- 
ment cease. 

Persons charged with crime, or convicted, maj^ be confined in the 
asylum by order of the court. 

When a person is decided to be insane by the examining justices, or 
by a court before which he is charged with offence, the court of his 
county or corporation shall appoint a " committee," which shall have 
the charge of his person and his estate. 

Patients are admitted into the hospital by a unanimous vote of its 
examining: board. 



460 APTENDIX. 



WEST VIRGINIA. 

" On an application on behalf of a person for his admission into the 
hospital [for the insane], the examining board may receive him as a 
patient therein . . ." This board consists of the superintendent of 
the hospital, and one or more of its directors. The board examines 
and inquires into the mental condition of the offered patient, as well as 
into the expediency and the terms of his admission. 

" Any justice who shall suspect any person in his county to be a 
lunatic, shall issue his warrant, ordering such person to be brought be- 
fore him. He shall inquire whether such person be a lunatic, and, for 
that purpose, summon a physician and any other witnesses." If he find 
the person to be a lunatic and to require confinement, he shall order his 
removal to the hospital for the insane, — provided the person be a citizen 
of West Virginia. The justice may, however, in his discretion, deliver 
him into the custody of relatives or friends upon satisfactory security 
for his safe and proper keeping, until well, or till returned to the sheriff 
to be disposed of according to law. 

Persons adjudged lunatic, and ordered to the hospital, who cannot 
be received there, shall be confined in jail till a vacancy occurs in the 
hospital, or till legally discharged. 



KENTUCKY. 

The several Circuit and Chancery Courts have power and jurisdiction 
over the insane resident in their respective counties. They have the 
power to appoint " committees " for the persons and estates of those 
adjudged insane. Inquisitions of lunacy may be made by these and by 
some other judicial functionaries. The subject of inquisition must be 
in court, and the issue tried by a jury. If the judge be dissatisfied 
with the verdict, he may set it aside and order a new inquest. 



TENNESSEE. 

A certificate from one or more reputable physicians, is the only legal 
form necessary in placing a private patient in the state hospital. 

Persons chargeable upon the county or the state are committed to 
the hospital by any justice of the peace. Any respectable citizen makes 
a written statement of belief that the person in question is insane, that 



APPENDIX. 461 

the disease is of less than two years' duration, or that he is unsafe to be 
at large, and that he is indigent ; and that certain witnesses named in 
the statement will testify to its truth. One of these witnesses must be 
a respectable physician. The justice summons and examines these 
witnesses, and such others as he deems fit. If satisfied of the existence 
of insanity as alleged, he requires the plrysician to certify to the fact. 
Then the justice himself writes a certificate setting forth his belief that 
the party is insane, and u his being at large is injurious to himself, and 
disadvantageous, if not dangerous to the community," and that he is 
properly chargeable for support in the hospital upon the county or the 
state. These two certificates justify the commitment of a patient to 
the hospital. 

The discharge of all patients upon recovery is within the province of 
the superintendent of the hospital in which they were placed. This 
officer has power to discharge immediately any person whom he believes 
not to be insane, or to be otherwise an unfit inmate. He is bound by 
oath not to enter into anj^ combination to oppress or deprive any person 
of his or her civil rights. 

The County Courts, on information of lunacy and incapacity, call a 
jury of twelve to inquire as to mental condition and as to property. If 
the jury decide against the sanity of the party, the court appoints a 
guardian or guardians. 



NORTH CAROLINA. 

Complaint to a justice, and examination before three, and the subse- 
quent proceedings, are the same here as in Virginia. Express provision 
is made, however, for the calling of at least one medical witness. 

If the superintendent doubts the fitness of a certain case for hospital 
treatment, he convenes the board of supervisors to decide the point. 

The guardian of any person found insane by a jury, ma}' be compelled 
to place him in the asylum if he be proved mischievous. 

When a person accused of crime is found b} T a jury to have been 
insane at time of offence, he may be placed in the asylum by the per- 
mission of a judge of the Superior Court. 

Application for appointment of guardian is made to the County 
Court, — a jury being summoned to decide as to sanity of the party. 



462 APPENDIX 



SOUTH CAROLINA. 

Persons complained of as lunatic are brought before a justice of the 
quorum, who calls to his aid two physicians of the state. A party 
being found lunatic is ordered to the hospital, unless deemed incurable 
and harmless. Persons found insane by inquisition from the Court of 
Chancery, or on trial in a court of common law, or on request of hus- 
band or wife, or next of kin, may be admitted to the insane hospital. 

Judges of the Court of Sessions may send to the asylum persons 
charged with crime, if found to be insane. 

GEORGIA. 

Complaint of lunacy is made to the justices of the inferior courts in 
their respective counties. A jury of seven, including one physician, is 
summoned. These hear evidence, examine accused, and determine as 
to mental condition. Friends or relatives are to receive ten days' 
notice of hearing. The justice may commit to the state insane asylum, 
and may fix the expenses of maintenance upon patient, or his relatives, 
or the county. He has also full power to appoint guardians of person 
and estate. The wife of an insane man shall be appointed as one of his 
guardians if she comply with the legal requirements. Another guardian 
is appointed to act with her. 

Recommitment to the asylum, after three months' absence, requires a 
repetition of the original forms. 

ALABAMA. 

A person in indigent circumstances may be placed in the insane 
hospital at the expense of his county. Application is made to a judge 
of Probate, who calls witnesses, one to be a respectable physician, and 
investigates the mental condition of the person and his financial re- 
sources. He may at discretion call a jury to his aid. If satisfied that 
the party is insane and poor, he shall order his commitment to the 
hospital as above. 

When a pauper becomes insane, the fact must be reported to a judge 
of Probate, who investigates the case, calling medical testimony, and if 
he deem the case likely to be benefited by hospital treatment, he orders 
his commitment to the hospital at the county charge. 

When a person has been acquitted of crime or misdemeanor, or has 
escaped indictment, on the ground of insanity, the fact shall be certified 
to the court, who thereupon shall carefully inquire whether the insanity 
still continues. If it do, the court shall order his confinement in the 
hospital. 



APPENDIX. 463 

Any person in confinement, under indictment, or for want of bail for 
good behavior, or for keeping the peace, or appearing as a witness, &c. 
&c, who shall appear to be insane, shall be the subject of careful inves- 
tigation by the circuit judge of the county where confined. This judge 
shall call medical and other testimoiry, and at his discretion, a jur}\ 
Satisfied of his insanity, the judge may discharge him from imprison- 
ment and place him in the hospital, there to remain till cured. Then, 
if the judge shall have so directed, the superintendent shall inform said 
judge and the sheriff of the patient's recovery, whereupon he shall be 
remanded to prison to await the proceedings proper in the case. 

When a jury shall find a person insane the Court of Probate shall 
appoint a guardian of his person and estate. Whenever recovery shall 
be alleged, supported by certificates of two plvysicians, a hearing shall 
be had before the judge of Probate. The guardians shall be cited to 
appear; and if he resist removal, a day shall be appointed for a jury- 
trial, as on the original inquiry. If the jury find the party sane, the 
guardian is liable at the discretion of the judge to be taxed with the 
costs ; otherwise the petitioner shall bear costs. 

MISSISSIPPI. 

Any persons whom the trustees and superintendent ma} T consider fit 
subjects for treatment shall be received as pay patients in the state 
hospital, upon the certificate of insanity signed by a respectable phy- 
sician. 

Upon complaint of any citizen of the same county that a certain 
lunatic is allowed to go at large in said county, it is the duty of the 
Court of Probate to summon a jury of twelve to make inquisition. If a 
majority of this jury declare the person to be insane, the court orders 
his commitment to the asylum. 

Whether placed in the asylum in the manner just mentioned, or by 
the voluntary act of his friends, the estate of the lunatic is chargeable 
with the expenses of his commitment and support. 

Persons acquitted of crimes or misdemeanors may be committed to 
the asylum on a certificate from the Circuit Court judge that they were 
acquitted on the ground of insanity. The same course seems to be 
allowed in cases of persons accused, not brought to trial. These last, 
on recoveiy, are returned to the place whence thej^ came, to answer the 
charges against them, — if this was required by the judge committing. 
Those persons, tried and acquitted, who are sent to the asylum are to 
be held " until restored to right mind." Expenses are chargeable to 
the patient's estate, or to the state. 

Inspectors of the penitentiary, on recommendation of the physician, 



464 APPENDIX. 

may place any insane convict under their charge in the asylum to re- 
main till restored to sanity, " or discharged by the expiration of his 
sentence." If cured before expiration of sentence he is to be returned 
to the penitentiary. 

The superintendent shall discharge patients — not criminal — when 
satisfied of recovery ; or satisfied that they are unfit subjects ; or on 
application of relatives or friends, if these give proper evidence of 
ability to provide for them. This officer is bound by oath to enter into 
no " combination to oppress or deprive any person of his or her liberty 
or civil rights." 

Upon request of relatives, friends, or overseer of the poor, the 
Orphans' Court summons a juiy of twelve men to inquire into the capa- 
city of an alleged lunatic. If the jur}^ find him insane, the court 
appoints one or more guardians of his person and estate, — to be under 
its supervision. 

MISSOURI. 

As in Arkansas and Kansas, it is the duty of friends, and failing 
these, of certain officers, to make complaint against persons furiously 
mad, or so disordered as to be dangerous to persons or property, and to 
confine them till they can be brought before the court. The complaint 
is addressed to the County Court. The court summons a jury, to decide 
as to sanity, and if the jury deem the party insane, the judge appoints 
a guardian of person and estate. 

Patients are admitted to the insane hospital upon order of court, or 
upon application of friends with certificate of two physicians. 

The state executive has power to transfer criminals from the peni- 
tentiary to the hospital for the insane. 

ARKANSAS. 

The provisions for complaint, temporary confinement, and trial of 
lunacy in this state are almost precisely the same as in Kansas, except 
that the summoning of a jury is not obligatory upon the judge of Pro- 
bate. If the judge, with or without a jury, decide that the party is 
insane, he appoints a guardian of person and estate. The judge may 
order confinement, and has the general supervision of guardian and 
ward. Petitions for the removal of guardianship are decided upon in 
the same way as the original application. 

If in the course of any legal procedure the question of lunacy be 
raised, a jury shall be summoned forthwith to decide that question. 
The same course is pursued with criminals under death-sentence, at the 



APPENDIX. 465 

petition of the sheriff. In case the jury give a verdict of insanity, the 
governor suspends sentence till recovery. 

LOUISIANA. 

No person subject to habitual madness, even with lucid intervals, 
shall be allowed charge of his property or person. A petition for inter- 
diction may be signed by blood relatives, by husband or wife, or by a 
stranger ; or the courts may request interdiction, after hearing counsel 
for accused — chosen by himself or by the judge. The interdiction is 
granted by the judge of the parish where the part}' resides. The judge 
hears or reads evidence, examines patient either personally or by proxy, 
and may require examination and affidavit from physician as to mental 
condition. If found insane, a curator is appointed by the judge to care 
for person and estate. Another person is appointed as superintendent 
of the person interdicted, having access to him at all times, and report- 
ing health and welfare to the judge once in three months. 

TEXAS. 

Complaint of lunacy may be made to any chief justice of a county, 
setting forth that A. B. is lunatic, and that the welfare of himself or 
others requires his restraint. The justice then summons a jury of 
twelve men to make return of " sound mind or not," having the accused 
in court. When the jury render a verdict of unsound mind, and that 
restraint is desirable, the justice may commit to the insane asylum, or, 
upon satisfactory security for proper care and safe-keeping, deliver the 
accused into the custody of his friends, to be restrained " until cause 
of confinement ceases." He also determines the responsibilit}^ for 
expenses. 

Patients may be placed in the hospital on a written request of guar- 
dian, near relative, or friend, or of persons or counties liable for their 
support. Such request must be sworn to as to truth of representations 
made, and accompanied hy a sworn certificate of insanity from a phy- 
sician, dated within two months. 

Criminals or persons charged with crime, found to be insane, may be 
committed to the insane asj'lum b} r the courts, there to be confined till 
released by the same authority. 

Guardianship is effected precisely as restraint is procured, as stated 
in the first paragraph, by a county justice and jury, the part}' being 
present. 

30 



466 APPENDIX. 

The reader will have observed that, in placing a person in a hospital 
for the insane, in England, every step in the process is regulated by 
some form prescribed by law. In this country, even in those states 
whose law requires a certificate of insanity and the application of a 
friend, no form is prescribed. That is left to the parties who offer them. 
Most of the hospitals have certain printed forms which they require to 
be used for this purpose. The following are the forms used by the 
Pennsylvania Hospital for the Insane : 

CERTIFICATE OF PHYSICIANS. 

"We certify that, after a personal examination of made within 

one week of the date of this certificate, we find to be insane, and a proper 

subject for hospital treatment. 

_1870. M.D. 

1870. M.D. 

CERTIFICATE OF MAGISTRATE OR JUDICIAL OFFICER. 

I certify that the foregoing certificate was duly acknowledged and to 

before me, this of 1870, that the signatures thereto are genuine, 

and that the signers are physicians of respectability. 




APPLICATION. 

I request that the above-named may be admitted as a patient into 

the Pennsylvania Hospital for the Insane. 

1870. } 

(To be signed by a guardian, relative, or friend.) 

The following are required by the McLean Asylum, at Somerville, 
Mass., and the Butler Hospital, at Providence, R. I., the certificate for 
the McLean being signed by two physicians : 

CERTIFICATE. 

I hereby certify that of is insane. 

1871. M.D. 

APPLICATION. 

I hereby request that the above-named insane person be admitted into the 



(To be signed by a relative or some responsible person.) 



INDEX. 



Absinthe, insanity from drinking, 81 
Access to patients may be denied, 404 
Acts of the insane, 174 
Acute delirious mania, vide Mania. 

dementia, vide Dementia. 

diseases, insanity in, 89 

mania, vide Mania. 

melancholia, vide Melancholia. 
Age, influence of, 139 
Agricultural counties, insanity in, 145 
Alabama, laws respecting insane, 462 
Alcohol, imbecility from, 80 

insanity from, 79 

paralysis from, 291 
Alleged delusions to be verified, 412 
Alteration in emotional state, 59 

in stage of general paralysis, 271 
Antimony, tartrate of, 255 
Arachnoid, appearance of, 111 
Arkansas, laws respecting insane, 464 
Arnold, definition of mania, 807 
Arteries, hypertrophy of walls of, 115 

sheaths of, 116 

twisting of, 116 
Association, Medico-psychological, clas- 
sification of, 125 
Asylum, not necessary for all the insane, 
382 

objections to, 375 

on the choice of an, 385 

use of an, 376 
Atavism, 136 

Attacks, previous, Dr. Sankey on, 353 
Attendants, 378 

B. 

Bain, Prof., division of mind, 311 
Bastian, Dr., on blocking of vessels, 111 
Baths in acute delirium, 245 

shower, in acute dementia, 229 
Bleeding in insanity, 247 
Blocking of vessels, 111 
Blood-supply of brain, 31 
Blow, insanity after a, 81 



Bodily disease amongst the insane, 369 
Bonnet, Dr. H., on general paralysis, 302 
Boyd, Dr., on tuberculosis in the insane, 

100 
Brain, chemistry and physics of, 30 

convolutions characteristic of hu- 
man, 29 
holes in substance of, 117 
morbid appearances of, 110 
Broadbent, Dr., arrangement of brain- 
fibres, 28 
Brodie, Sir B., on neuralgia with in- 
sanity, 95 
Brougham, Lord, on the knowledge of 

right and wrong, 324 
Brutus, feigned imbecility of, 386 
Bucknill, Dr., divisions of insanity, 311 

C. 

California, laws respecting insane, 459 
Calmeil, M., account of general paralysis, 

270 
Cannabis Indica in mania, 255 
Casper on impulsive insanity, 330 
Causes of death amongst insane, 367 
insanity, predisposing, 132 
exciting, moral, 146 
physical, 150 
Cerebrum, convolutions of, 22 
Certificates, the two medical, 399 

copies to be sent to Commissioners, 

404 
duration of, 401 
form of, 401 

one sometimes sufficient, 398 
who may sign, 399 
Chances of life amongst insane, 366 
" Change of life " in women, 70 
Change of scene in treatment of insanity, 

196 
Characteristics of commencing insanity, 

59 
Chemistry of brain, 30 
Child, mind of a, 40 
Chloral, hydrate of, 198, 205, 224, 254 



468 



INDEX. 



Chronic insane, treatment of, 371 
Civilization and insanity, 142 
Clarke, Dr. Lockhart, account of nerve- 
cells, 22 
on holes in the brain, 117 
Classification, various principles of, 127 

points to be observed in, 128 
Clouston, Dr., on rheumatism and in- 
sanity, 93 
on tuberculosis and insanity, 100 
Coke, Lord, on the term non compos 

mentis, 310 
Commission of lunacy, 413 
when advisable, 414 
may be superseded, 415 
Commissioners in lunacy, prosecutions 

by, 404 
Conditions of healthy mind, 51 

life in insanity, 142 
Congress, international, classification of 

the, 124 
Connecticut, laws respecting insane, 447 
Connective tissue, changes in, 119 

increase of, 119 
Conversation with a patient, 410 
Counties, agricultural, insanity in, 145 
Cotton, Dr., on phthisis and insanity, 
101 



David, feigned dementia of, 386 
Death, causes of, amongst insane, 367 

notice of, to be sent, 406 
Delaware, laws respecting insane, 453 
Delirium, acute, 231 

tremens, 78 
Delusions alleged must be verified, 412 

commonly found, 160 

definition of, 153 

exalted, 159 

gloomy, 156 

how to be met, 381 

insanity without, 305 

prognosis, 163 

rise of, 155 

the test of insanity, 308 
Demented patients, examination of, 420 
Dementia, acute or primary, 226 
treatment of, 229 

chronic, 344 

cases of, 346 

senile, 292 
Dickinson, Dr., appearances in diabetes, 

118 
Digitalis, in insanity, 255 
Dipsomaniacs, examination of, 422 
Discharge, notice of, to be sent, 406 
Diseases, bodily, amongst insane, 369 
District of Columbia, laws respecting in- 
sane, 454 
Dress, fantastic, 177 



Drink, imbecility from, 80 
Drinking, habitual, 179, 422 

Drunkenness, 77 

E. 

Ear, tumor of, amongst the insane, 122 
Early symptoms of insanity, 195 

treatment of, 1 95 
Early treatment, importance of, 373 
Eating of the insane, 178 
Emotions, on the, 46 
Emotional state, alteration in, 59 

insanity, 313 
Epilepsy, insanity with, 90 

with moral insanity, 320 
Epileptic paralysis, 293 
Epileptiform, attacks in general paralv- 

sis, 278 
Erotomania, 189 
Erskine, Lord, on delusions, 309 
Esquirol on classification, 123 
Examination of patients, 416 
Extremes, the two, of insanity, 192 

F. 

Feeding by force in acute melancholia, 
215 

by nasal tube, 220 

by Paley's apparatus, 218 

by Dr. H. Stevens, 221 

by Dr. H. Tuke, 219 

by Dr. Williams, 215 

by stomach-pump, 221 
Feelings, the, 45 

vary according to condition of cen- 
tres, 48 
Feigned insanity, 386 

dementia, 389 

mania, 389 

on the detection of, 390 
Folie circulaire, 87 
Food, 53 

in melancholia, 205 
Forcible feeding, vide Feeding. 

G. 

Gangrene of lung in melancholia, 225 
General paralysis of the insane, vide Pa- 
ralysis. 
Georgia, laws respecting insane, 462 
Gout with insanity, 92 
Gray, Dr., cases of homicidal insanity, 

332, 334 
Gray matter of brain, 22 
Guislain, classification of, 123 

H. 

Hrematoma auris, 122 

Hale, Lord, on partial insanity, 308 



INDEX. 



469 



Hallucinations, definition of, 153 

denote insanity, 164 

explanation of, 166 

of hearing, 169 

seat of, 165 

of sight, 166 
smell, 171 
taste, 172 
touch, 172 
Head, insanity with disease of, 96 
Heart, 98 

Heat, insanity from, 83 
Hemispheres, removal of, in animals, 27 
Hereditary predisposition, 133 

insanity from, terminates in two 
ways, 137 

prognosis in, 138 

statistics of, 138 
Homicide, insane, of various kinds, 186 
Hydrocyanic acid in insanity, 255 

I. 

Ideas, 43 

Idiopathic insanity, 87 

Illinois, laws respecting insane, 455 

Illusion, definition of an, 154 

Imbecility, 326 

characteristics, 338 

cases, 340 

examination of patients, 418 

from drink, 80 

treatment of, 331 
Impulsive, insanity, 327 
Indecent exposure, 176 
Indian hemp, insanity from, 80 

in treatment, 255 
Indiana, laws respecting insane, 455 
Infant, mind in an, 39 
Insane, odor of the, 392 
Insanity, climacteric, 70 

concealed, 358 

feigned, 386 

idiopathic, 87 

impulsive, 327 

metastatic, 92 

puerperal, 71, 262 

recurrent, 86, 361 

senile, 84 

sexual, 68 
Insanity from absinthe, 81 

acute disease, 89 

alcohol, 76 

a blow, 81, 263 

epilepsy, 90, 266 

heat, 83 

Indian hemp, 80 

masturbation, 74, 260 

mental anxiety, 66 

mental shock, 64 

peripheral irritation, 102 

sunstroke, 83, 264 



Insanity of puberty, the, 69, 259 
Insanity with neuralgia, 95 

rheumatism or gout, 92, 265 
syphilis, 94, 264 
tuberculosis, 99 
diseases of head, 96 
heart, 98 
kidnev, 99 
liver, "98 
stomach, 99 
without delusions, 305 
Insanity, is it on the increase ? 144 
the legal test of, 224 
terminations of, 349 
Intellect, the, 44 
Intervals, lucid, 363 
Intestine, displacement of large, 99 
Iowa, laws respecting insane, 457 
Ireland, increase of insanity in, 146 



Johnson, Dr. George, on hypertrophy of 

arteries, 115 
Joire, M., on morbid anatomy of general 

paralysis, 115 
Jury, patient may demand a, 414 

K. 

Kane, Dr., Arctic Explorations, 53, 55 
Kansas, laws respecting insane, 458 
Kentucky, laws respecting insane, 460 
Kidney, insanity with disease of, 99 
Kleptomania, 190 
Knowledge of right and wrong, the, 325 



Law of lunacy, 393 

Lead paralysis, 292 

" Leave of absence," 407 

Legal documents not to be executed, 363 

test of insanity, 224 
Life, chances of, amongst insane, 366 
Light, 55 

Lindsay, Dr. L., insanity in Arctic coun- 
tries, 55 
Liver, insanity with disease of, 98 
Louisiana, laws respecting insane, 465 
Lucid intervals, 363 
Lunacy, Commission of, 413 

Commissioners in, 404-407, 412 

Law of, 393 
Lunatics, dangerous, 355, 411 

improperly treated, 410 

pauper, 408 

private, 394 

property of, 412 

wandering, 410 
Lungs, insanity with disease of, 99 
Lyndhurst, Lord, on the test of in- 
sanity, 324 



470 



INDEX. 



M. 

Maine, laws respecting insane, 442 
Mania, acute conscious, 251 
medicines in, 254 
prognosis, 256 
treatment, 253 
acute delirious, 231 
diagnosis, 248 
prognosis, 247 
treatment, 242 

without acute symptoms, 257 
Marriage of the predisposed, 134 
Maryland, laws respecting insane, 453 
Massachusetts, laws respecting insane, 445 
Masturbation, insanity of, 74 

treatment of, 260 
Maudsley, Dr., classification, 124 

on asylum restraint, 384 

on impulsive insanity, 329 
Medical certificates, the two, 399 
Medicine, why study of insanity is a 

branch of, 17 
Medicines in the early stage of insanity, 

198 
Melancholia, 200 

climacteric, 201 

delusions of, 156, 160, 200 

food in, 205 

medicines in, 204 

moral treatment of, 208 

prognosis in, 208 

suicidal, 203 

treatment of, 203 

acute, 213 

forcible feeding in, 215 

refusal of food in, 214 
Melancolie avec stupeur, 210 
Mental symptoms indicate pathological 

state, 104 
Michigan, laws respecting insane, 455 
Minnesota, laws respecting insane, 457 
Mississippi, laws respecting insane, 463 
Missouri, laws respecting insane, 464 
Monomania, 268 
Moral insanity, 311 

Dr. Prichard on, 311 

in the aged, 321 

intellectual defect in, 319 

prognosis, 323 

treatment, 323 

with epilepsy, 320 
Moral treatment of the insane, 379 
Morbid appearances in acute insanity, 
109 

chronic insanity, 114 

general paralysis, 298 
Morel, M., classification of, 123 
Morphia in melancholia, 205 

acute melancholia, 224 



Morphia not to be given in acute delir- 
ium, 244 
Mutilation, Self-, 183 

N. 

Nerve-cells, arrangement of, 22 

degeneration of, 119 

calcareous, 119 

fatty, 119 

pigmentary, 119 
Nerve-centres, 21 

fibres, 26 

function, study of, twofold, 34 

tubes, atrophy of, 119 
Neuralgia, insanity with, 95 
Nevada, laws respecting insane, 458 
New Hampshire, laws respecting insane, 

443 
New Jersey, laws respecting insane, 450 
New York, laws respecting insane, 449 
Nicholl, Sir John, on delusions, 308 
Noble, Dr., classification of, 123 
North Carolina, laws respecting insane, 

461 
Notice of death of patients, 406 

discharge, 406 
Nymphomania, 73 

O. 

Objective study of mind, 35 

Occupation, 380 

Odor of the insane, 392 

Ohio, laws respecting insane, 454 

Opium, insanity from, 81 

in melancholia, 205 

not to be given in acute delirium, 
244 
"Order" for reception of a lunatic, 395 

duration of, 396 

form of, 395 

who may sign, 396 

P. 

Paralysis, alcoholic, 291 

epileptic, 293 

general, of the insane, 269 

age of patients, 285 

cases of, 287 

causes of, 294 

diagnosis of, 287 

discovery of, 269 

does not attack chronic lunatics, 285 

pathology of, 301 

post-mortem appearances, 298 

prognosis in, 294 

recovery only apparent, 281 

stages, three, of, 271 

terminations of, 280 
Pathology of insanity, 57 



INDEX. 



471 



Pauper patients, 408 

Pennsylvania, laws respecting insane, 

451 
Peripheral irritation, insanity with, 102 
Pinel, classification of, 123 
Post-mortem appearances, 107 

in general paralysis, 298 
Poverty a cause of insanity, 145 
Predisposition hereditary, 133 
Prichard, Dr., on moral insanity, 311 

his cases of, 313 
Puerperal insanity, 71, 262 
Pupil in general paralysis, 279 
Purgatives in acute delirium, 246 
Pyromania, 189 



Eecoveries, imperfect, 352 
statistics of, 350 

Recovery, how to be recognized, 353 
apparent, in general paralysis, 281 

Recurrent insanity, 86, 361 

Release of dangerous patients to be re- 
fused, 355 

Retreat, statistics of the York, 350 

Rheumatism with insanity, 92 

Rhode Island, laws respecting insane, 
446 

Rindfleisch on connective tissue, 119 

Rokitansky on ditto, 119 

Rutherford on morbid appearances in 
brain, 118 

S. 

Sankey, Dr., on the arteries in insanity, 
115 

Schroeder van der Kolk, divisions of in- 
sanity, 63 

Senile insanity, 84 

Sex of the insane, 140 

general paralytics, 285 

Shower-bath in acute dementia, 229 

" Single" patients, 404 

Skae, Dr., his classification, 63 

Sleep, 55 

in acute delirium, 241 

Sound mind, what is meant by, 57 

South Carolina, laws respecting insane, 
462 

Squandering of property, 185 

"Statement," the, following the "or- 
der," 397 
of mental and bodily health, 404, 405 

Statistics of insanity, 350 

Stevens, Dr. H., feeding by stomach- 
pump, 221 

Stomach, insanity with disease of, 99 

Stomach-pump, feeding by, 221 . 

Stratagem, to be avoided, 418 



Stripping naked, the habit of, 176 
Study of mind, twofold, 34 
Subjective method of study, 35 
Subjects of conversation with a patient, 

410 
Sunstroke, insanity from, 83 
Sutherland, Dr., on disease of heart, 98 
Sympathetic insanity, 63 
Syphilitic insanity, 63, 264 



Temperature, 53 

Tennessee, laws respecting insane, 460 
Terminations of insanity, 349 
Test, the legal, of insanity, 224 
Texas, laws respecting insane, 465 
Thurnam, Dr., on statistics of insanity, 
138 

on insanity in agricultural counties, 
145 
Tongue, the, in acute delirium, 241 

in melancholia, 205 
" Transfer, order of," 407 
Transitory mania, 232 
Treatment, the, of chronic insane, 371 

importance of early, 373 

moral, 379 
Tuberculosis, insanity with, 99 
Tuke, Dr. Batty, on morbid anatomy, 
118 

classification, 127 

Dr. Daniel, divisions of mind, 311 

Dr. Harrington, on feeding by nasal 
tube, 219 
Turkish bath in melancholia, 225 

V. 

Vaso-motor nerves, 33 
Ventricles, lining membrane of, 121 
Vermont, laws respecting insane, 444 
Virginia, laws respecting insane, 459 
Visit to an alleged lunatic, 409 

W. 

Wandering lunatics, 410 

Weber, Dr., on insanity after acute dis- 
ease, 89 

Westphal, Dr., pathology of general 
paralysis, 303 

West Virginia, laws respecting insane, 
460 

Wet sheet, the, 236 

Will, the, 49 

Willis, circle of, 32 

Wisconsin, laws respecting insane, 456 

Witnesses, medical, 414 

Y. 

York Retreat, statistics of the, 350 



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